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REQUEST FOR CONTINUATION OF FUNDING FOR PbR EXCLUSION F.A.O: From: Your designation: Your contact details: PbR excluded Drugs Team North West London Commissioning Support Unit E-mail: [email protected] Tel: E-mail: Date: Before providing patient identifiable data below, I can confirm that the patient (or in the case of a minor or vulnerable adult with the parent/legal guardian/carer) has given appropriate explicit consent for sensitive personal information on this form to be passed to the CCG and/or CSU for processing this request for further funding and validating subsequent invoices. Consent given: ☐Yes I would like to request further funding for the following: Drug name: Indication: Ranibizumab ☐ Aflibercept ☐ Macular Oedema secondary to Retinal Vein Occlusion Central ☐ Branch ☐ Patient NHS number: Hospital no: Patient birth year: GP Practice Code: GP Practice Postcode: I herewith provide you with the requested information: 1. This request is for continued treatment of the same eye(s)* ☐ Yes 2. Please confirm which eye(s) is/are to be treated and their current visual acuity (BCVA) ☐Left Eye – BCVA: ☐Right Eye – BCVA: 3. Visual acuity has continued to improve? ☐ Yes 4. Visual acuity has not yet been stable for 3 consecutive months? 7. What is acquisition cost of drug including VAT (if applicable)? ☐ No ☐ No ☐ Yes ☐ No £ /0.5mg injection *A new application is required for: Repeat treatment of the same eye because the visual acuity deteriorates following treatment withdrawal after initial response. Note: Funding will only be re-approved if the patient has shown an improvement of visual acuity Treatment of the other eye I look forward to your response in due course. Document1