21Forms for supply and use of botulinum toxin pharmaceutical benefit under this Special Arrangement

21 Forms for supply and use of botulinum toxin pharmaceutical benefit under this Special Arrangement

(1) An eligible medical practitioner must not administer a botulinum toxin pharmaceutical benefit under this Special Arrangement unless the eligible medical practitioner has completed, for each administration of a botulinum toxin pharmaceutical benefit, a Patient Usage Form. (2) The Patient Usage Form must be signed by: (a) the eligible medical practitioner; and (b) either: (i) the patient; or (ii) if the patient is not able to sign the form—the patient’s agent; or (iii) if the patient is aged less than 16 years—the patient’s parent or legal guardian. (3) The Patient Usage Form must contain the following information: (a) the date that the botulinum toxin pharmaceutical benefit was administered; (b) the patient’s Medicare number; (c) the patient’s full name; (d) a form of agreement to receive the treatment, given by: (i) the patient; or (ii) if the patient is not able to sign the form—the patient’s agent; or (iii) if the patient is aged less than 16 years—the patient’s parent or legal guardian; (e) the botulinum toxin pharmaceutical benefit administered; (f) the quantity of the botulinum toxin pharmaceutical benefit administered; (g) the remaining number of vials of the botulinum toxin pharmaceutical benefit held by the eligible medical practitioner; (h) the condition for which the botulinum toxin pharmaceutical benefit was administered; (i) evidence of: (i) the registered practice location at which the botulinum toxin pharmaceutical benefit was administered; and (ii) the full name and address of the eligible medical practitioner who administered the botulinum toxin pharmaceutical benefit; (j) the provider number of the eligible medical practitioner who administered the botulinum toxin pharmaceutical benefit to the patient. (4) An eligible medical practitioner must not administer a botulinum toxin pharmaceutical benefit under this Special Arrangement to an eligible patient unless, before the first administration of the botulinum toxin pharmaceutical benefit in a treatment period, a Patient Acknowledgment Form has been completed and signed by: (a) the eligible medical practitioner; and (b) either: (i) the patient; or (ii) if the patient is not able to sign the form—the patient’s agent; or (iii) if the patient is aged less than 16 years—the patient’s parent or legal guardian.

Note: The Patient Usage Form and the Patient Acknowledgment Form can be obtained from the Medicare website.