Methoxy Polyethylene Glycol-Epoetin Beta (Mircera®)
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
Treatment of anemia requiring transfusion, defined as a haemoglobin level of less than 100g per litre, where intrinsic renal disease, as assessed by a nephrologist, is the primary cause of the anemia.
Specialist Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
*To be completed by the specialist initiating drug treatment, and retained by the hospital Pharmacy Department.
April 2010