Tenofovir with Emtricitabine and Efavirenz
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
Initial treatment of HIV infection in a patient with a CD4 count of less than 500 per cubic millimetre or symptomatic HIV disease.
Continuing treatment of HIV infection where the patient has previously received PBS-subsidised therapy for HIV infection.
Specialist /Authorised Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
Additional information to be provided by authorised general practitioners only:
| Provider Number: | ____________________________________ |
| Practice Address: | ____________________________________ |
| Telephone Number: | ____________________________________ |
*To be completed by the specialist or authorised prescriber initiating drug treatment, and retained by the hospital Pharmacy Department.
March 2012