REQUEST FOR CONTINUATION OF FUNDING FOR PbR EXCLUSION
F.A.O:
From:
Your designation:
Your contact details:
PbR excluded Drugs Team
North West London Commissioning Support Unit
E-mail: NWLCSU.NWLmedmgt@nhs.net
Tel:
E-mail:
Date:
Before providing patient identifiable data below, I can confirm that the patient (or in the case of a minor or
vulnerable adult with the parent/legal guardian/carer) has given appropriate explicit consent for sensitive
personal information on this form to be passed to the CCG and/or CSU for processing this request for
further funding and validating subsequent invoices. Consent given: ☐Yes
I would like to request further funding for the following:
Drug name:
Botulinum toxin A (Botox®)
Indication:
Prevention of headache in chronic migraine
Patient NHS number:
Hospital no:
Patient birth year:
GP Practice Code:
GP Practice Postcode:
I herewith provide you with the requested information:
Number of treatment
cycles received
(1 cycle = 12 weeks)
cycles
Number of headache days per month
Pre-treatment with
Current:
Botulinum toxin A
days
days
% change compare to
baseline
%
1. There has been an adequate response to initial 2 treatment cycles and
any subsequent treatment cycles (latter if applicable)
☐ Yes
☐ No
2. Patient has >30% reduction in headache days per month compared to
baseline (pre-treatment)?
☐ Yes
☐ No
3. Patient still has more than 15 headache days per month for 3
consecutive months (i.e. has not changed to episodic migraine)
☐ Yes
☐ No
4. Patient started treatment with Botulinum toxin A less than 2 years ago
☐ Yes
☐ No
£
/treatment cycle
7. What is acquisition cost of drug including VAT (if applicable)?
I look forward to your response in due course.
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