Commonwealth/State Highly Specialised Drugs Program, Victoria, Australia - Appendix 5: Certification by Prescribing Doctor

Contents	Program Information	Appendix 1 - AHMAC	Appendix 2 - Drugs Covered by the Program	Appendix 3 - Agreed Prices
Appendix 4 - Patient Eligibility Criteria	Appendix 5 - Certification	Appendix 6 - Community prescribers of AIDs & Hep C medications	Appendix 7 - Auditing Requirements	Appendix 8 - Claiming Procedures

The certification form must contain the following elements:

patient's name

patient's UR number

patient's Medicare number (or other proof of eligibility to receive a pharmaceutical benefit)

drug name

Pharmaceutical Benefits Advisory Committee approved clinical indications for the specific drug

a statement from the prescriber to the effect:

"I certify that the above named patient meets the Pharmaceutical Benefits Advisory Committee's criteria for the prescription of the Drug name ."

prescribing doctor's signature

prescribing doctor's name & title

date

In the case of GP's authorised to prescribe HIV/AIDs drugs the additional information:

provider number; and

practice address and phone number.

Click to access a Generic Certification by Prescribing Doctor form or you may wish to design your own form that contains the above elements.

Contact: Michael Furey Tel (03) 9096 2506 Fax (03) 9096 9205

Last updated: 30 April, 2008
This web site is managed and authorised by the Ambulance & Acute Programs Section of the Metropolitan Health and Aged Care Services Division of the Victorian State Government, Department of Health, Australia

For general enquiries to the Department of Health telephone 61 3 90960000