APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Transcription

1 APPLICANT (stamp sticker acceptable) Page 1 Fm SA1603 Insulin Pumps INITIAL APPLICATION - permanent neonatal diabetes Applications only from a relevant specialist nurse practitioner. Approvals valid f 3 months. Patient has permanent neonatal diabetes A MDI regimen trial is inappropriate Has been evaluated by the multidisciplinary team f their suitability f insulin pump therapy Patient/Parent/Guardian has undertaken carbohydrate counting education (either a carbohydrate counting course direct education from an appropriate health professional) Applicant is part of a multidisciplinary team experienced in the management of type 1 diabetes care Applicant is a nurse practitioner wking within their vocational scope RENEWAL - permanent neonatal diabetes Applications only from a relevant specialist nurse practitioner. Approvals valid f 3 months. Patient is continuing to derive benefit accding to the treatment plan agreed at induction Patient remains fully compliant transition to MDI is considered inappropriate by the treating physician It has been at least 4 years since the last insulin pump received by the patient, in the case of patients qualifying under previous pump therapy f the initial application; the pump is due f replacement Applicant is a nurse practitioner wking within their vocational scope See also: INITIAL APPLICATION - severe unexplained hypoglycaemia p2, RENEWAL - severe unexplained hypoglycaemia p3, INITIAL APPLICATION - HbA1c p4, RENEWAL - HbA1c p5, INITIAL APPLICATION - Previous use befe 1 September 2012 p6 RENEWAL - Previous use befe 1 September 2012 p7 I confirm the above details are crect that in signing this fm I underst I may be audited.

2 APPLICANT (stamp sticker acceptable) Page 2 Fm SA1603 INITIAL APPLICATION - severe unexplained hypoglycaemia Applications only from a relevant specialist nurse practitioner. Approvals valid f 3 months. Patient has type 1 diabetes has undergone a pancreatectomy has cystic fibrosis-related diabetes Has undertaken carbohydrate counting education (either a carbohydrate counting course direct education from an appropriate health professional) Applicant is part of a multidisciplinary team experienced in the management of type 1 diabetes care Has adhered to an intensive MDI regimen using analogue insulins f at least six months Has had four severe unexplained hypoglycaemic episodes over a six month period (severe as defined as requiring the assistance of another person) Has an average HbA1c between the following range: equal to greater than 53 mmol/mol equal to less than 90 mmol/mol Has been evaluated by the multidisciplinary team f their suitability f insulin pump therapy Applicant is a nurse practitioner wking within their vocational scope See also: RENEWAL - severe unexplained hypoglycaemia p3, INITIAL APPLICATION - HbA1c p4, RENEWAL - HbA1c p5, INITIAL APPLICATION - Previous use befe 1 September 2012 p6 RENEWAL - Previous use befe 1 September 2012 p7 I confirm the above details are crect that in signing this fm I underst I may be audited.

3 APPLICANT (stamp sticker acceptable) Page 3 Fm SA1603 RENEWAL - severe unexplained hypoglycaemia Applications only from a relevant specialist nurse practitioner. Approvals valid f 3 months. Patient is continuing to derive benefit accding to the treatment plan agreed at induction of at least a 50% reduction from baseline in hypoglycaemic events HbA1c has not increased by me than 5 mmol/mol from baseline The pump is due f replacement Applicant is a nurse practitioner wking within their vocational scope See also: INITIAL APPLICATION - HbA1c p4, RENEWAL - HbA1c p5, INITIAL APPLICATION - Previous use befe 1 September 2012 p6 RENEWAL - Previous use befe 1 September 2012 p7 I confirm the above details are crect that in signing this fm I underst I may be audited.

4 APPLICANT (stamp sticker acceptable) Page 4 Fm SA1603 INITIAL APPLICATION - HbA1c Applications only from a relevant specialist nurse practitioner. Approvals valid f 3 months. Patient has type 1 diabetes has undergone a pancreatectomy has cystic fibrosis-related diabetes Has undertaken carbohydrate counting education (either a carbohydrate counting course direct education from an appropriate health professional) Applicant is part of a multidisciplinary team experienced in the management of type 1 diabetes care Has adhered to an intensive MDI regimen using analogue insulins f at least six months Has unpredictable significant variability in blood glucose including significant hypoglycaemia affecting the ability to reduce HbA1 In the opinion of the treating clinician, HbA1c could be reduced by at least 10 mmol/mol using insulin pump treatment Has typical HbA1c results between the following range: equal to greater than 65 mmol/mol equal to less than 90 mmol/mol Has been evaluated by the multidisciplinary team f their suitability f insulin pump therapy Applicant is a nurse practitioner wking within their vocational scope See also: RENEWAL - HbA1c p5, INITIAL APPLICATION - Previous use befe 1 September 2012 p6 RENEWAL - Previous use befe 1 September 2012 p7 I confirm the above details are crect that in signing this fm I underst I may be audited.

5 APPLICANT (stamp sticker acceptable) Page 5 Fm SA1603 RENEWAL - HbA1c Applications only from a relevant specialist nurse practitioner. Approvals valid f 3 months. Patient is continuing to derive benefit accding to the treatment plan agreed at induction of achieving maintaining a reduction in HbA1c from baseline of 10 mmol/mol The number of severe unexplained recurrent hypoglycaemic episodes has not increased from baseline The pump is due f replacement Applicant is a nurse practitioner wking within their vocational scope See also: INITIAL APPLICATION - Previous use befe 1 September 2012 p6 RENEWAL - Previous use befe 1 September 2012 p7 I confirm the above details are crect that in signing this fm I underst I may be audited.

6 APPLICANT (stamp sticker acceptable) Page 6 Fm SA1603 INITIAL APPLICATION - Previous use befe 1 September 2012 Applications only from a relevant specialist nurse practitioner. Approvals valid f 3 months. Patient has type 1 diabetes has undergone a pancreatectomy has cystic fibrosis-related diabetes Was already on pump treatment pri to 1 September 2012 had been evaluated by the multidisciplinary team f their suitability f insulin pump therapy at the time of initiating that pump treatment continues to benefit from pump treatment The patient has adhered to an intensive MDI regimen using analogue insulins f at least six months pri to initiating pump therapy The patient is continuing to derive benefit from pump therapy The patient had achieved is maintaining a HbA1c of equal to less than 80 mmol/mol on pump therapy The patient has had no increase in severe unexplained hypoglycaemic episodes from baseline The patient s HbA1c has not deteriated me than 5 mmol/mol from baseline The pump is due f replacement Applicant is a nurse practitioner wking within their vocational scope See also: RENEWAL - Previous use befe 1 September 2012 p7 I confirm the above details are crect that in signing this fm I underst I may be audited.

7 APPLICANT (stamp sticker acceptable) Page 7 Fm SA1603 RENEWAL - Previous use befe 1 September 2012 Applications only from a relevant specialist nurse practitioner. Approvals valid f 3 months. The patient is continuing to derive benefit accding to the treatment plan has maintained a HbA1c of equal to less than 80 mmol/mol The patient s HbA1c has not deteriated me than 5 mmol/mol fromthe time of commencing pump treatment The patient has not had an increase in severe unexplained hypoglycaemic episodes from baseline The pump is due f replacement Applicant is a nurse practitioner wking within their vocational scope I confirm the above details are crect that in signing this fm I underst I may be audited.