POAC Funded Zoledronate Infusion Subsidy

POAC Funded Zoledronate Infusion Subsidy Voucher

Application for subsidised zoledronate infusion for osteoporosis
Date *

Day Month Year
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 *

Yes No
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 *

Yes No
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? *

Yes No
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 Card Quintile 4 or 5 Neither 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 bisphosphonates Unsuitable for oral bisphosphonates Neither 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 Name Last Name
Practice name *
Patient details
Patient name *

First Name Last Name
NHI *
Date of birth

Day Month Year
Date
Ethnicity *
Address *
Where will patient have the infusion?

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

POAC Funded Zoledronate Infusion Subsidy Voucher