Download National National Cancer Drugs Fund Application Form

National
National Cancer Drugs Fund Application Form –
Bevacizumab
for Advanced Ovarian Cancer
(2nd line treatment)
Instructions to Consultants: Please fill in each section of the form electronically and save the
document with your own file name. [If you continue typing the boxes will enlarge to contain the text].
Please send electronically to ______________________. Please also send copies to your Trust’s link
accountant / corporate contracting team.
Security of Patient Identifiable Information: The patient will be identified by their NHS number only.
Please do not include any other patient identifiers for confidentiality reasons. All communication must be
sent to the Cancer Drugs Fund Office via secure e mail accounts: that is from an nhs.net account to the
____________ account.
Receipt of Application: The sender of the application will receive an acknowledgement, together with
details of the unique Cancer Drugs Fund reference.
Cancer Drugs Fund Policy: To check the status of a particular therapy please check the Cancer Drugs
Fund Policy at _________________
Applications will be subject to Clinical Audit arrangements.
Approved Treatment Required for Bevacizumab for Advanced Ovarian Cancer –
2nd line
TICK
All 7 conditions must be met
1. Application made by and first cycle of systemic anti-cancer therapy to be
prescribed by a consultant specialist specifically trained and accredited in
the use of systemic anti-cancer therapy
2. Platinum sensitive epithelial ovarian, fallopian tube or primary peritoneal
cancer (6 or more months after completion of first line chemotherapy)
3. 2nd line indication
4. Given with Carboplatin and Gemcitabine combination chemotherapy
5. PS 0 or 1
6. No previous treatment with bevacizumab or other anti-VEGF therapy
7. Bevacizumab dose to be 15mg/kg every 3 weeks
Note: Bevacizumab should be discontinued due to toxicity or disease progression,
which ever occurs first.
Consultant Approval (email authority)
Patient Consent Obtained (date of letter – copy to be retained on patient file)
National Cancer Drugs Fund – Application Form 1 April 2013
Bevacizumab for Advanced Ovarian Cancer – 2nd line
Page 1
Proposed Start Date for Therapy (add clinic date)*:
Consultant details*
(including signature or
email confirmation)
Name:
Hospital:
Address:
Post Code:
Telephone:
Nhs.net
Trust Pharmacist details of the Trust where
the patient will be
treated*
Mandatory - NHS No*:
Mandatory – Patients
date of birth*
Optional – Hospital No.
Clinical Commissioning
Group*
Patient’s GP*
(name, address,
telephone)
Name:
Hospital:
Address:
Post Code:
Telephone:
Nhs.net
NHS No:
DOB:
Hospital No:
CCG Name:
Name:
Address:
Post Code:
ICD-10 Code*
C56 – Malignant neoplasm of ovary
HRG Code
Completion of items marked with * is mandatory. Failure to complete these items may
mean that payment is not made.
National Cancer Drugs Fund – Application Form 1 April 2013
Bevacizumab for Advanced Ovarian Cancer – 2nd line
Page 2