Patient NHS No

For Commencing Treatment with BOTULINUM TOXIN B for cervical dystonia in accordance with the Bedfordshire and Luton Joint Prescribing Committee (JPC) Guidance on Botulinum Toxin Type B (Bulletin 223 approved February 2016)

Please note “Notification Only” means that if the patient fulfils the proforma / NICE criteria then provider Trusts can commence treatment without the need to wait for CCG acknowledgement / approval

Patient NHS No. / Trust: / GP Name:
Patient Hospital No. / Consultant Making Request: / GP code / Practice code:
Patient initials & DoB: / Consultant Contact Details: / GP Post code:

Bedfordshire and Luton CCGs have agreed to fund the use of Botulinum Toxin Type B for the treatment of cervical dystonia in patients who are no longer responsive to treatment with Botulinum- Toxin Type A. (JPC Policy Bulletin 223, Feb 2016)

Please tick to confirm indication and adherence to the policy requirement.

/ Please ensure this form is countersigned by Trust Chief Pharmacist (or deputy) before onward transmission to CCG.
Only fully completed forms will be accepted for consideration by the CCGs.
A full Individual Funding Request (IFR) will need to be completed if the request does not fulfil the policy requirements in full. IFR forms can be obtained from the relevant Individual Funding Co-ordinator.
Bedfordshire Clinical Commissioning Group (BCCG): (e-mail preferred method) or telephone 01494 555530. IFR team, South, Central and West CSU, Albert House, Queen Victoria Road, High Wycombe, HP11 1AG.
Luton Clinical Commissioning Group (LCCG) ; Secure fax: 01582 511054, The Lodge, 4 George St West, Luton, Beds, LU1 2BJ
Please confirm that the patient has cervical dystonia and has a loss of responsiveness to treatment with Botulinum Toxin – Type A.
I confirm that the patient (or in the case of a minor or vulnerable adult where the parent/guardian or legal carer) has given consent for the patient identifiable data on this form to be shared with the CCG Medicines Management / Optimisation or Contracts Team. This data may then be used 1. In the interests of the care of the patient 2. For clinical audit purposes 3. To validate against subsequent invoices.
What is acquisition cost of drug including VAT (if applicable)?
Give cost/ code of activity associated with treatment? / r Yes r No
r Yes r No
£……………..…/month
______

Trust contact e-mail in case of CCG query:

Consultant Signature (electronic signature acceptable)

Trust Chief Pharmacist (or deputy) signature (electronic signature acceptable)

Date

JPC Guidance, Bulletin 223, Feb 2016: The use of Botulinum Toxin Type B for the Treatment of Cervical Dystonia

JPC Recommendation:

· To approve the use of Botulinum toxin –Type B in patients with cervical dystonia who are no longer responsive to treatment with botulinum toxin – Type A’