Ganciclovir (Cymevene®, Vitrasert®)
Highly Specialised Drugs Program Declaration Form*
| Patient's Name: | ____________________________________ |
| Medical Record Number: | ____________________________________ |
| Medicare Number: | ____________________________________ |
I certify that the above patient meets the Pharmaceutical Benefits Advisory Committee's criteria for funding under Section 100 of the National Health Act, 1953.
Criteria
Tick box to indicate the criterion that applies
Prophylaxis of cytomegalovirus disease in bone marrow and solid organ transplant patients at risk of cytomegalovirus disease. (Infusion only).
Cytomegaloviral retinitis in severely immunocompromised patients. (Implant and infusion)
Specialist/ Authorised Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
Additional information to be provided by authorised general practitioners only:
| Provider Number: | ____________________________________ |
| Practice Address: | ____________________________________ |
| Telephone: | ____________________________________ |
*To be completed by the specialist or authorised prescriber initiating drug treatment, and retained by the hospital Pharmacy Department.
December 2005