APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Transcription

1 The patient has increased nutritional requirements APPLICANT (stamp sticker acceptable) Page 1 Fm SA1554 Stard Supplements (Ensure; Ftisip; Isosource; Jevity; Nutrison; Osmolite; Sustagen) INITIAL APPLICATION - Children - indications other than exclusive enteral nutrition f Crohn's disease Applications only from a dietitian, relevant specialist vocationally registered general practitioner. Approvals valid f 1 year. The patient has a condition causing malabsption The patient has failure to thrive Nutrition goal has been set (eg reach a specific weight BMI) RENEWAL - Children - indications other than exclusive enteral nutrition f Crohn's disease Applications only from a dietitian, relevant specialist, vocationally registered general practitioner general practitioner on the recommendation of a dietitian, relevant specialist vocationally registered general practitioner. Approvals valid f 1 year. The treatment remains appropriate the patient is benefiting from treatment A nutrition goal has been set (eg reach a specific weight BMI) INITIAL APPLICATION - Children - exclusive enteral nutrition f Crohn's disease Applications only from a gastroenterologist dietitian on the recommendation of a gastroenterologist. Approvals valid f 3 months. It is to be used as exclusive enteral nutrition f the treatment of Crohn's disease Dietitians must include the name of the gastroenterologist recommending treatment the date the gastroenterologist was contacted See also: RENEWAL - Children - exclusive enteral nutrition f Crohn's disease p2, INITIAL APPLICATION - Adults p2, RENEWAL - Adults p3, INITIAL APPLICATION - Sht-term medical condition p3, RENEWAL - Sht-term medical condition p4, INITIAL APPLICATION - Long-term medical condition p5 RENEWAL - Chronic disease OR tube feeding f patients who have previously been funded under Special Authity fms SA0702 SA0583 p6 I confirm the above details are crect that in signing this fm I underst I may be audited.

2 Patient has a BMI of less than 20 kg/m² unintentional weight loss greater than 5% within the last 3-6 months Using over the counter supplements (e.g. Complan) APPLICANT (stamp sticker acceptable) Page 2 Fm SA1554 Stard Supplements (Ensure; Ftisip; Isosource; Jevity; Nutrison; Osmolite; Sustagen) - continued RENEWAL - Children - exclusive enteral nutrition f Crohn's disease Applications only from a gastroenterologist, dietitian on the recommendation of a gastroenterologist vocationally registered general practitioner on the recommendation of a gastroenterologist. Approvals valid f 3 months. Prerequisites (tick boxes, write the data requested in the space provided where appropriate) It is to be used as exclusive enteral nutrition f the treatment of Crohn's disease General Practitioners dietitians must include the name of the gastroenterologist recommending treatment the date the gastroenterologist was contacted:... INITIAL APPLICATION - Adults Applications only from a dietitian, relevant specialist vocationally registered general practitioner. Approvals valid f 3 months. Patient is Malnourished Patient has a body mass index (BMI) of less than 18.5 kg/m² Patient has unintentional weight loss greater than 10% within the last 3-6 months Patient has not responded to first-line dietary measures over a 4 week period by: Increasing their food intake frequency (eg snacks between meals) Using high-energy foods (e.g. milkshakes, full fat milk, butter, cream, cheese, sugar etc) A nutrition goal has been set (e.g. to reach a specific weight BMI) See also: RENEWAL - Adults p3, INITIAL APPLICATION - Sht-term medical condition p3, RENEWAL - Sht-term medical condition p4, INITIAL APPLICATION - Long-term medical condition p5 RENEWAL - Chronic disease OR tube feeding f patients who have previously been funded under Special Authity fms SA0702 SA0583 p6 I confirm the above details are crect that in signing this fm I underst I may be audited.

3 Patient has a BMI of less than 20 kg/m² unintentional weight loss greater than 5% within the last 3-6 months Is undergoing a bone marrow transplant Tempomibular surgery glossectomy APPLICANT (stamp sticker acceptable) Page 3 Fm SA1554 Stard Supplements (Ensure; Ftisip; Isosource; Jevity; Nutrison; Osmolite; Sustagen) - continued RENEWAL - Adults Applications only from a dietitian, relevant specialist, vocationally registered general practitioner general practitioner on the recommendation of a dietitian, relevant specialist vocationally registered general practitioner. Approvals valid f 6 months. A nutrition goal has been set (eg reach a specific weight BMI) Patient is Malnourished Patient has a body mass index (BMI) of less than 18.5 kg/m² Patient has unintentional weight loss greater than 10% within the last 3-6 months INITIAL APPLICATION - Sht-term medical condition Applications only from a dietitian, relevant specialist vocationally registered general practitioner. Approvals valid f 1 year. Is being fed via a nasogastric tube a nasogastric tube is to be inserted f feeding Malignancy is considered likely to develop malnutrition as a result Pregnant Patient is in early pregnancy (<13 weeks) has severe clinical hyperemesis gravidarum requiring admission to hospital is unlikely to meet her nutritional requirements due to continuing hyperemesis gravidarum Patient has clinical hyperemesis gravidarum continuing past 13 weeks either there is concern that the patient is unlikely to meet the Institute of Medicine s (1990) recommended weight gain guidelines f pregnancy the patient s weight has not increased past her booking/pre-pregnancy weight Patient is having multiple births is under the care of an obstetric team who consider the nutritional needs of the patient are not being met See also: RENEWAL - Sht-term medical condition p4, INITIAL APPLICATION - Long-term medical condition p5 RENEWAL - Chronic disease OR tube feeding f patients who have previously been funded under Special Authity fms SA0702 SA0583 p6 I confirm the above details are crect that in signing this fm I underst I may be audited.

4 Has undergone a bone marrow transplant Tempomibular surgery glossectomy APPLICANT (stamp sticker acceptable) Page 4 Fm SA1554 Stard Supplements (Ensure; Ftisip; Isosource; Jevity; Nutrison; Osmolite; Sustagen) - continued RENEWAL - Sht-term medical condition Applications only from a dietitian, relevant specialist, vocationally registered general practitioner general practitioner on the recommendation of a dietitian, relevant specialist vocationally registered general practitioner. Approvals valid f 1 year. Is being fed via a nasogastric tube Malignancy is considered likely to develop malnutrition as a result Pregnant Patient is in early pregnancy (<13 weeks) has severe clinical hyperemesis gravidarum requiring admission to hospital is unlikely to meet her nutritional requirements due to continuing hyperemesis gravidarum Patient has clinical hyperemesis gravidarum continuing past 13 weeks either there is concern that the patient is unlikely to meet the Institute of Medicine s (1990) recommended weight gain guidelines f pregnancy the patient s weight has not increased past her booking/pre-pregnancy weight Patient is having multiple births is under the care of an obstetric team who consider the nutritional needs of the patient are not being met See also: INITIAL APPLICATION - Long-term medical condition p5 RENEWAL - Chronic disease OR tube feeding f patients who have previously been funded under Special Authity fms SA0702 SA0583 p6 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 SA1554 Stard Supplements (Ensure; Ftisip; Isosource; Jevity; Nutrison; Osmolite; Sustagen) - continued INITIAL APPLICATION - Long-term medical condition Applications only from a dietitian, relevant specialist vocationally registered general practitioner. Approvals valid without further renewal unless notified. Is being fed via a tube a tube is to be inserted f the purpose of feeding (not nasogastric tube - refer to specific medical condition criteria) Cystic Fibrosis Liver disease Chronic Renal failure Inflammaty bowel disease Chronic obstructive pulmonary disease with hypercapnia Sht bowel syndrome Bowel fistula Severe chronic neurological conditions Epidermolysis bullosa AIDS (CD4 count < 200 cells/mm³) Chronic pancreatitis See also: RENEWAL - Chronic disease OR tube feeding f patients who have previously been funded under Special Authity fms SA0702 SA0583 p6 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 SA1554 Stard Supplements (Ensure; Ftisip; Isosource; Jevity; Nutrison; Osmolite; Sustagen) - continued RENEWAL - Chronic disease OR tube feeding f patients who have previously been funded under Special Authity fms SA0702 SA0583 Applications only from a dietitian, relevant specialist, vocationally registered general practitioner general practitioner on the recommendation of a dietitian, relevant specialist vocationally registered general practitioner. Approvals valid without further renewal unless notified. Is being fed via a tube a tube is to be inserted f the purpose of feeding (not nasogastric tube - refer to specific medical condition criteria) Cystic Fibrosis Liver disease Chronic Renal failure Inflammaty bowel disease Chronic obstructive pulmonary disease with hypercapnia Sht bowel syndrome Bowel fistula Severe chronic neurological conditions I confirm the above details are crect that in signing this fm I underst I may be audited.