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Cancellation of Schedule 8 treatment permits

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Do you need to complete this form?
This form is for prescribers who wish to cancel their permit to prescribe Schedule 8 drugs.Do not use this form if you are a prescriber who would like to cancel your permit to treat an opioid dependent person with opioid replacement therapy. Use Notification of termination of methadone or buprenorphine program.

Registered Medical Practitioner / Nurse Practitioner Details

Cancellation of Schedule 8 treatment permits
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Your Details (Prescriber Details)

Patient Details

Cancellation of Schedule 8 treatment permits
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Patient Details

Cancellation Details

Cancellation of Schedule 8 treatment permits
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Cancellation Details

Reason for cancellation *

Declaration

Cancellation of Schedule 8 treatment permits
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Declaration

I, confirm the information I provided in this application is true and complete to the best of my knowledge. I confirm that I wish to cancel the Schedule 8 permit I hold for .

Privacy Collection Notice

By completing this form, you acknowledge that you are providing the personal and health information as required under the Drugs, Poisons and Controlled Substances Act 1981 (the Act) to the Department of Health, Victoria (the Department) for the purpose of notifying the Department in relation to a Schedule 8 treatment permit.

The information is handled by the Department in accordance with the requirements of the Act, Drugs, Poisons and Controlled Substances Regulations 2017 (Vic), Privacy and Data Protection Act 2014 (Vic), Health Records Act 2001 (Vic) and the Department’s privacy policy.

The information collected by the Department:

•will be used and disclosed for the purposes of assessing a permit application;•will be used and disclosed for monitoring and compliance purposes;•may be disclosed to other relevant health practitioners when necessary to facilitate coordination of the patient's drug treatment and safe prescribing of drugs (if applicable); and•may be disclosed for any other purposes permitted by law including but not limited to reporting or investigation of suspected unlawful activity to regulatory and law enforcement agencies in the Commonwealth, States and Territories; and Ahpra.
You can download a PDF copy of the completed form or request a confirmation email at the Submission Complete page.

For further information about Victorian Drugs and Poisons legislation, please visit the Medicines and Poisons Regulation website at www.health.vic.gov.au/dpcs.

For further information on privacy and how to access and seek correction of personal information about you held by the Department, visit www.health.vic.gov.au/privacy.

Remember Me

You can save time filling out the form by ticking the checkbox below. Your Prescriber Details will be saved and future use of this form on this computer will automatically populate with your Prescriber Details. Do not tick the checkbox below if this is a public/shared computer as it may compromise your privacy and security.
By unticking the checkbox below the Prescriber Details that have been saved on this computer will be removed.
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Department of Health (VIC) - Medicines and Poisons Regulation