National Cancer Drugs Fund Application Form –

Ofatumumab

for Chronic Lymphocytic Leukaemia

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 Ofatumumab for Chronic Lymphocytic Leukaemia / TICK
Bothconditionsmust be met
  1. a) 2nd line indication, OR
b)3rd line indication
  1. Patient refractory to treatment with Fludarabine combination and/or Alemtuzumab OR treatment with Fludarabine combination and/or Alemtuzumab contra-indicated

Consultant Approval (email authority)
Patient Consent Obtained (date of letter – copy to be retained on patient file)

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* / Name:
Hospital:
Address:
Post Code:
Telephone:
Nhs.net
Mandatory - NHS No*:
Mandatory – Patients date of birth*
Optional – Hospital No. / NHS No:
DOB:
Hospital No:
Clinical Commissioning Group* / CCG Name:
Patient’s GP*
(name, address, telephone) / Name:
Address:
Post Code:
ICD-10 Code* / C91.1 – Chronic lymphocytic leukaemia of B-cell type
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 2013Page 1

Ofatumumab for Chronic Lymphocytic Leukaemia