Special Authority application
Form SA1291
Freestyle Optium Blood glucose test strips
Please send Applications to:
PHARMAC
PO BOX 10 254
Wellington
Phone:
Facsimile:
Email:
0800 66 00 50
(04) 974 4788
[email protected]
[email protected]
Patient Details – patient sticker is acceptable
Surname:
First Name/s:
NHI No:
D.O.B
Address:
Phone no
Home:
Work:
Mobile
Applying Physician – patient sticker is acceptable
Name
Practice Address:
Phone
Fax:
Email:
Prerequisites; both of the following required.
Patient was testing both for blood ketones and blood glucose using the FreeStyleOptium
(previously named OptiumXceed) blood glucose meter prior to 1 June 2012 - attach evidence.
Patient has received one or more subsidised prescriptions for FreeStyleOptium (previously
OptiumXceed) Blood Ketone test strips prior to 1 June 2012 - attach evidence.
Note: Please provide copies of details/receipts of subsidised pharmacy dispensingʼs for both
FreeStyleOptium blood glucose test strips and Freestyle Optium blood ketone test strips prior
to June 2012.
Signed
Date