Get Immunoglobulin Authorisation Request Forms National Blood Authority

This guide provides a step-by-step approach to completing the Immunoglobulin Authorisation Request Forms required for NSW patients. By following these instructions, users can ensure that the form is filled out correctly and efficiently, facilitating the request process for immunoglobulin therapy.

Follow the steps to complete the Immunoglobulin Authorisation Request Form.

1. Click 'Get Form' button to obtain the form and open it for editing.
2. Begin by filling out the requesting medical officer section. Include your name, pager or mobile number, position, fax, and phone number.
3. Provide patient details including surname, given names, date of birth, gender, UR number, hospital, weight, and height.
4. Indicate the treating facility where the patient has been clinically reviewed and the administering facility where the immunoglobulin will be infused.
5. For product delivery instructions, enter the dispenser's name and contact details, including street address, suburb, state, postcode, phone, fax, and email. Include any additional delivery instructions as needed.
6. Answer the previous immunoglobulin treatment question by selecting yes, no, or unknown. Provide details if applicable.
7. Select the patient's diagnosis from the provided neurological conditions or specify other conditions if necessary. You may attach a consultant's letter for verification.
8. Indicate the required induction and maintenance doses, including the specific dates and frequencies.
9. Include relevant test results and functional criteria if available. Also, indicate the concomitant use of immunosuppressive therapy and details of any plasma exchange trials.
10. Select your preferred imported IVIg product, ensuring it aligns with hospital policies.
11. Complete the office use section with necessary authorisation details, ensuring the delegate, qualifying criteria, and product approval are noted.
12. Once all fields are completed accurately, review the form for completeness. Save all changes made, and subsequently download, print, or share the form as required.

Ensure you complete and submit the Immunoglobulin Authorisation Request Form to facilitate the patient's access to necessary immunoglobulin products.