"Special Authorization Request Form - Venous Thromboembolism (Vte) Prevention Following Surgery" - Newfoundland and Labrador, Canada

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SPECIAL AUTHORIZATION REQUEST FORM
The Newfoundland and Labrador Prescription Drug Program (NLPDP)
Venous Thromboembolism (VTE) Prevention Following Surgery
Pharmaceutical Services
Department of Health and Community Services
Phone:
(709) 729-6507
P.O. Box 8700, Confederation Bldg.
Toll Free Line:
1-888-222-0533
St. John’s, NL A1B 4J6
Fax:
(709) 729-2851
Patient Information
Patient Name
Date of Birth
NLPDP Drug Card/MCP Number
Address
□ Rivaroxaban (Xarelto)
□ Apixiban (Eliquis)
□ LMWH __________________
Dosage: _______________
Duration (Period After Discharge): ________
Prevention of venous thromboembolism for the following (in hospital + after discharge) period
after surgery:
Total Hip Replacement (THR) 32-38 Days
Date of Surgery:
______________
Total Knee Replacement (TKR) 10-14 Days
Date of Surgery:
______________
Hip Fracture Surgery 35 Days (LMWH only)
Date of Surgery:
______________
Abdominal or Pelvic Surgery for Cancer 10-28 Days
(Lovenox only)
Date of Surgery:
______________
Risk Factors following abdominal or pelvic surgery for cancer:
Patient has a history of venous thromboembolism (VTE)
Anesthesia lasted more than 2 hours
Bed rest lasted more than 4 days following surgery
Coverage is considered for the period after discharge following surgery.
Date thromboprophylaxis was started in hospital:
______________
Date of Discharge:
______________
Comments:
 Physician
 Other Health Professional
Prescriber Information / Requested By:
Prescriber Name:
(please print)
License Number:
Address:
Phone Number:
Fax Number:
Signature:
Date:
Pharmacist Name:
Pharmacy Name:
(optional)
(optional)
Please note that Special Authorization Requests normally take approximately 10 working days to be processed.
Version May 2017 – Replaces previous forms
SPECIAL AUTHORIZATION REQUEST FORM
The Newfoundland and Labrador Prescription Drug Program (NLPDP)
Venous Thromboembolism (VTE) Prevention Following Surgery
Pharmaceutical Services
Department of Health and Community Services
Phone:
(709) 729-6507
P.O. Box 8700, Confederation Bldg.
Toll Free Line:
1-888-222-0533
St. John’s, NL A1B 4J6
Fax:
(709) 729-2851
Patient Information
Patient Name
Date of Birth
NLPDP Drug Card/MCP Number
Address
□ Rivaroxaban (Xarelto)
□ Apixiban (Eliquis)
□ LMWH __________________
Dosage: _______________
Duration (Period After Discharge): ________
Prevention of venous thromboembolism for the following (in hospital + after discharge) period
after surgery:
Total Hip Replacement (THR) 32-38 Days
Date of Surgery:
______________
Total Knee Replacement (TKR) 10-14 Days
Date of Surgery:
______________
Hip Fracture Surgery 35 Days (LMWH only)
Date of Surgery:
______________
Abdominal or Pelvic Surgery for Cancer 10-28 Days
(Lovenox only)
Date of Surgery:
______________
Risk Factors following abdominal or pelvic surgery for cancer:
Patient has a history of venous thromboembolism (VTE)
Anesthesia lasted more than 2 hours
Bed rest lasted more than 4 days following surgery
Coverage is considered for the period after discharge following surgery.
Date thromboprophylaxis was started in hospital:
______________
Date of Discharge:
______________
Comments:
 Physician
 Other Health Professional
Prescriber Information / Requested By:
Prescriber Name:
(please print)
License Number:
Address:
Phone Number:
Fax Number:
Signature:
Date:
Pharmacist Name:
Pharmacy Name:
(optional)
(optional)
Please note that Special Authorization Requests normally take approximately 10 working days to be processed.
Version May 2017 – Replaces previous forms
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