Government of Ontario: Ministry of Health and Long-Term Care

Visudyne Therapy Registration/Funding Enrolment

This registration form must be completed and signed by the attending ophthalmologist for each visudyne treatment.

The collection of the information on this form is authorized by Clause 23(b) of O Reg 965, s.23, O. Reg 376/92, s.1. under the Public Hospitals Act R.S.O. 1980, Chapter 410 for the purpose of assessing monitoring patient use of verteporfin and payment therefore. For information about collection practices contact: INFOLINE TEL. 416 327-4327, Toll Free 1 800 387-5559, or TTY 1 800 268-1154.

Name of physician

OHIP Billing no.

OGPMSS Client no.

Practice location

Name of visudyne program hospital

Facility number

Name of patient

Health Number

Sex Male Female

Date of birth(dd/mm/yyyy)

Treatment

Left eye #1 #2 #3 #4 #5 #6 Date(dd/mm/yyyy)

Right eye #1 #2 #3 #4 #5 #6 Date(dd/mm/yyyy)

Diagnosis ADM Subfoveal CNV Predominantly Classic
Secondary to Pathological Presumed Ocular Histoplasmosis Syndrome
Date of most recent angiogram(dd/mm/yyyy)

Eligibility Criteria for Reimbursement

i. The patient has predominantly classic subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD), pathologic myopia, or presumed ocular histoplasmosis syndrome. ‘Predominantly’ means that the area of classic subfoveal CNV is equal to or greater than 50% of the total CNV lesion, as determined by fluorescein angiography and documented by retinal photographs retained on the patient’s permanent medical record: and
Yes No

ii. treatment is commenced within 30 months after initial diagnosis of predominantly classic subfoveal CNV secondary to either AMD or pathologic myopia; and
Yes No

iii. the patient’s visual acuity is equal to or worse than 20/40’ and
Yes No

iv. for each repeat therapy, recurrent or persistent CNV leakage is detected by fluorescein angiography and documented by retinal photographs retained on the patient’s permanent medical record.
Yes No

Certification of eligibility criteria by the authorized treating physician

Physician signature

Date

Visudyne shipment approved by hospital

Authorized signature

Date

White - Patient Canary - Hospital pharmacy Pink - Treating physician