POAC Funded Zoledronate Infusion Subsidy

POAC Funded Zoledronate Infusion Subsidy Voucher

Application for subsidised zoledronate infusion for osteoporosis
Date*

DayMonthYear
The voucher for subsidy of $80 is valid for one month from the date of application.
POAC funding criteria
Patient resides in CMDHB catchment area and is eligible for publicly funded health services*

YesNo
PATIENT IS NOT ELIGIBLE FOR SUBSIDY

Patient must reside in CMDHB and be eligible for public health funding in New Zealand.

DHB Boundary Map VIEW HERE

Meets Special Authority Criteria*

YesNo
PATIENT IS NOT ELIGIBLE FOR SUBSIDY

Patient must meet the Pharmac Special Authority criteria for osteoporosis.

Refer Zoledronic acid inj 0.05 mg per ml, 100 ml.

Is the patient able to self fund the cost of the infusion?*

YesNo
PATIENT IS NOT ELIGIBLE FOR SUBSIDY

This subsidy is only available where the patient is unable to self fund the cost of the infusion.

Confirm the patient meets one of the following*

Holds Community Services CardQuintile 4 or 5Neither of the above
PATIENT IS NOT ELIGIBLE FOR SUBSIDY

Patient must EITHER hold a current Community Services Card, OR is quintile 4 or 5.

Oral therapy*

Unable to tolerate oral bisphosphonatesUnsuitable for oral bisphosphonatesNeither of the above
PATIENT IS NOT ELIGIBLE FOR SUBSIDY

There must be documented intolerance to oral bisphosphonates

OR

Oral therapy must be unsuitable (i.e. unable to remain upright for 30 mins after infusion, cognitive issues that prevent compliance,P1NP suggestive that oral bisphosphonates not effective)

Referrer details
Referring doctor*

First NameLast Name
Practice name*
Patient details
Patient name*

First NameLast Name
NHI*
Date of birth

DayMonthYear
Date
Ethnicity*
Address*
Where will patient have the infusion?

At the referring doctors clinicAt another infusion centre
Name of Infusion Centre patient will attend*
Should be Empty:

POAC Funded Zoledronate Infusion Subsidy Voucher