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National Cancer Drugs Fund Application Form – Cetuximab for Advanced Head and Neck Cancer 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 Cetuximab for Advanced Head and Neck Cancer – use with standard 1st line palliative chemotherapy TICK All 4 conditions must be met 1. Advanced Head and Neck Cancer 2. Use with standard 1st line palliative combination chemotherapy 3. Performance status 0 or 1 4. No previous treatment with Cetuximab 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 Cetuximab for Advanced Head and Neck Cancer Use with standard 1st line palliative chemotherapy 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* C49 – Connective and soft tissue of head, face and neck 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 Cetuximab for Advanced Head and Neck Cancer Use with standard 1st line palliative chemotherapy Page 2