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 Elaprase®

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 Exceptional Access Program (EAP), 5700 Yonge Street, 3rd floor, Toronto ON M2M 4K5. For copies of this and other EAP forms, please visit http://www.health.gov.on.ca/en/pro/programs/drugs/eap_mn.aspx

The Executive Officer (EO) of Ontario Public Drug Programs considers requests for coverage of drug products not listed in the Ontario Drug Benefit Formulary under the Exceptional Access Program (EAP). This form is intended to facilitate requests for drugs considered under the EAP. The EO may request additional documentation to support the request. Please ensure that all appropriate information for each section is provided to avoid delays.

Section 1 – Prescriber Information



Type of Prescriber


Mailing address


Fax no.
Telephone no.
Section 2 – Patient Information



Ontario Health Insurance Number

- -

Gender

   



   

Section 3 – Drug, Dosage and Regimen


Section 4 – Clinical Information – New Request

Please provide enzymology testing report AND mutation analysis report

Details on Musculo-Skeletal (MSK) function





and results of orthopedic assessment, if available






Section 5 – Clinical Information –Renewal Request

Neurocognitive Status, performed by a clinical psychologist (Every 3–5 years; Require consult report) and audiometry results, if available

Details on Musculo-Skeletal (MSK) function





and results of orthopedic assessment, if available






Section 6 – Current Medication Use and Co-Morbid Conditions


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 the Ontario Drug Programs Help Desk at 1 800 668–6641 or contact the Director, Drug Programs Delivery Branch, 5700 Yonge St., 3rd Floor, Toronto ON  M2M 4K5.