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

Ontario Public Drug Programs (OPDP)
Drug Programs Delivery Branch
5700 Yonge St., 3rd floor
Toronto ON  M2M 4K5

Request for Aldurazyme®

Please fax completed form and/or any additional relevant information to 416 327-7526 or toll-free 1 866 811-9908; or send to the Ontario Public Drug Programs (OPDP), 3rd floor, 5700 Yonge Street, Toronto ON  M2M 4K5. For copies of this and other forms, please visit http://www.health.gov.on.ca/en/public/forms/odb_fm.aspx

This form is intended to facilitate the submission of requests for funding consideration. Additional documentation to support the request may be required. Please ensure that all appropriate information for each section is provided to avoid delays.

Section 1 – Prescriber Information



Mailing Address





Fax No.

Telephone No.

Section 2 – Patient Information



Gender

   


       

Section 3 – Drug, Dosage and Regimen


Section 4 – Clinical Information – New Request


Please provide enzymology testing report AND mutation analysis report.


Hurler-Scheie (require 1 or more clinical features of MPS I below to be eligible for reimbursement):

Please provide overnight sleep study, respiratory function tests, cardiac tests, and joint contracture tests.


Hurler (For patients with less than 2 severe mutations identifi ed, require 1 or more clinical features of MPS I below to be eligible for reimbursement):

AND



AND

Section 5 – Clinical Information – Renewal Request

Hurler-Scheie:

An improvement or stabilization/no progression of disease activity in ALL of the following clinical features:

Please provide overnight sleep study, respiratory function tests, cardiac tests, and joint contracture tests


Hurler:

No renewal requests will be accepted, as HSCT should be completed.

Section 6 – Current Medication Use and Co-Morbid Conditions

List of current medication use AND document serious co-morbid conditions, if any.

The information on this form is collected under the authority of the Personal Health Information Protection Act, 2004, S.O. 2004, c.3, Sched. A (PHIPA) and Section 13 of the Ontario Drug Benefit Act, R.S.O. 1990c.O.10 and will be used in accordance with PHIPA, as set out in the Ministry of Health and Long-Term Care "Statement of Information Practices", which may be accessed at www.health.gov.on.ca. If you have any questions about the collection or use of this information, call Ontario Public Drug Programs at 1 866 811–9893 or contact the Director, Drug Programs Delivery Branch, 5700 Yonge St., 3rd Floor, Toronto ON  M2M 4K5.




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4846-87E (2016/02)       © Queen’s Printer for Ontario, 2016