Follow the steps to successfully complete your application online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Fill in the patient details section, which includes the patient's NHI, gender, date of birth, last name, first name, middle name, and address. Ensure that all fields marked with an asterisk are filled out.
3. In the DHB of domicile field, specify the relevant district health board associated with the patient.
4. Complete the applicant section, providing your NZMC number, title, full name, department or practice address, DHB, email address, phone number, extension, and facsimile.
5. Identify any additional contacts that need to be informed about the application, such as a Hepatitis C nurse, and complete their contact information as required.
6. If you are not the patient’s GP, provide the relevant GP details so that PHARMAC can notify them of the application outcome.
7. Enter the nominated delivery address ensuring it is an appropriate location where someone is available to accept delivery.
8. Answer the access criteria questions, providing thorough details about the patient’s condition, genotype, and the status of treatment.
9. Attach any supporting documents or clinic letters that are relevant to the patient's situation.
10. Review the declaration section, confirm that all information is accurate, and sign and date the application.
11. Once completed, save changes, and you can download, print, or share the form as needed.

Start your application online today to ensure timely access to necessary treatments.