PATIENT CONSENT FORM
Attach this form to prescriptions for s100 Highly Specialised Drugs
		
IMPORTANT INFORMATION FOR PATIENTS

Community pharmacists have to charge a co-payment when they sell medicines. The NSW Government has made changes to co-payments for Section 100 (s100) Highly Specialised Drugs, for NSW residents who are patients of NSW public hospitals or authorised community prescribers in NSW. The NSW Government will now pay the co-payment. By signing this form, you agree that the co-payment you are charged for your medicine/s will be paid by the NSW Government.

When you fill your prescription at a NSW public hospital or community pharmacy you will need to present this form to the pharmacist with your prescription (including any repeats).

It is important that you keep this form attached to your prescription (including any repeats) each time.

PATIENT AGREEMENT
I agree to the NSW Government paying the co-payment on my behalf for my medicine/s. This is in line with the National Health Act 1953 (Cth) and the National Health (Highly Specialised Drugs Program for Hospitals) Special Arrangement 2010. I understand that:
• the pharmacist may collect health information about me and my medicine/s
• this information will be given to NSW Health to make the co-payment
• NSW Health may also use this information to evaluate this program
• My health information will be protected in accordance
with NSW privacy legislation and the NSW Health Privacy Manual for Health Information.

SIGNATURE OF PATIENT OR AUTHORISED REPRESENTATIVE

Printed full name:   

<<Patient Demographics:Full Name>>

Signature:

Date signed: <<Miscellaneous:Date>>

FOR FURTHER INFORMATION PLEASE SPEAK WITH YOUR DOCTOR OR PRESCRIBER.	INFORMATION FOR PRESCRIBERS

By completing this form, I agree that the patient:
• is a NSW resident and patient of a NSW public hospital prescriber or authorised community prescriber in NSW
• is eligible to have their s100 Highly Specialised Drug co-payment paid by the NSW Government.

PRESCRIBER USE ONLY

PATIENT DETAILS
Patient’s full name:

<<Patient Demographics:Full Name>>

Patient’s address:  

<<Patient Demographics:Full Address>>

Date of prescription/s: <<Date of prescription/s>>

Repeats:<<Repeats>>

PRESCRIBER DETAILS

Prescriber’s full name:  <<Doctor:Name>>
Prescriber number:       <<Doctor:Provider Number>>

Hospital/practice name:  

<<Practice:Name>>

Prescriber’s address and phone:

<<Doctor:Address>>

Ph: <<Doctor:Phone>>

PRESCRIBER SIGNATURE

Date signed: <<Miscellaneous:Date>>	

For more information about changes to Section 100 co-payments
visit www.health.nsw.gov.au/pharmaceutical/Pages/s100-copayments.aspx