National Cancer Drugs Fund Application Form – Ponatinib For Chronic Myeloid Leukaemia with T315I Mutation Instructions to Consultants: Please fill in each section of the form electronically and save the document with your own file name. [If you continue typing the boxes will enlarge to contain the text]. Please send electronically to ______________________. Please also send copies to your Trust’s link accountant / corporate contracting team. Security of Patient Identifiable Information: The patient will be identified by their NHS number only. Please do not include any other patient identifiers for confidentiality reasons. All communication must be sent to the Cancer Drugs Fund Office via secure e mail accounts: that is from an nhs.net account to the ____________ account. Receipt of Application: The sender of the application will receive an acknowledgement, together with details of the unique Cancer Drugs Fund reference. Cancer Drugs Fund Policy: To check the status of a particular therapy please check the Cancer Drugs Fund Policy at _________________ Applications will be subject to Clinical Audit arrangements. Approved Treatment Required for Ponatinib for the treatment of Chronic Myeloid TICK Leukaemia with T315I Mutation All 4 conditions must be met Application made by and first cycle of systemic anti-cancer therapy to be prescribed by a consultant specialist specifically trained and accredited in the use of systemic anti-cancer therapy Chronic Myeloid Leukaemia a. Chronic Phase OR b. Accelerated Phase OR c. Blast Phase Documented T315I mutation Consultant Approval (email authority) Patient Consent Obtained (date of letter copy to be retained on patient file) – Proposed Start Date for Therapy (add clinic date)*:
National Cancer Drugs Fund Application Form – Ponatinib For Chronic Myeloid Leukaemia with T315I Mutation Instructions to Consultants: Please fill in each section of the form electronically and save the document with your own file name. [If you continue typing the boxes will enlarge to contain the text]. Please send electronically to ______________________. Please also send copies to your Trust’s link accountant / corporate contracting team. Security of Patient Identifiable Information: The patient will be identified by their NHS number only. Please do not include any other patient identifiers for confidentiality reasons. All communication must be sent to the Cancer Drugs Fund Office via secure e mail accounts: that is from an nhs.net account to the ____________ account. Receipt of Application: The sender of the application will receive an acknowledgement, together with details of the unique Cancer Drugs Fund reference. Cancer Drugs Fund Policy: To check the status of a particular therapy please check the Cancer Drugs Fund Policy at _________________ Applications will be subject to Clinical Audit arrangements. Approved Treatment Required for Ponatinib for the treatment of Chronic Myeloid Leukaemia with T315I Mutation TICK All 4 conditions must be met Application made by and first cycle of systemic anti-cancer therapy to be prescribed by a consultant specialist specifically trained and accredited in the use of systemic anti-cancer therapy Chronic Myeloid Leukaemia a. Chronic Phase OR b. Accelerated Phase OR c. Blast Phase Documented T315I mutation Consultant Approval (email authority) Patient Consent Obtained (date of letter – copy to be retained on patient file) Proposed Start Date for Therapy (add clinic date)*:
Ponatinib_CMLT315I_ver1.0.docx