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Getting Started

Notifications and records to be submitted to Medicines and Poisons Regulation

Fields marked with * are required

Who should complete this form?

This form is intended to enable a pharmacist or other health practitioners to satisfy either of the following requirements by providing copies of relevant records and corresponding information.

To comply with section 32A of the Drugs Poisons and Controlled Substances Act 1981, a pharmacist who is requested or directed to supply or dispense Schedule 4 or Schedule 8 poisons or any other drugs of dependence in greater quantities or more frequently than appears to be reasonably necessary is required to report the matter to Medicines and Poisons Regulation branch.

To comply with regulation 109 of the Drugs Poisons and Controlled Substances Regulations 2017, a pharmacist is required to retain dispensing records (and other records of supply) in a readily retrievable form for 3 years and to produce those records on demand to an authorized officer of Medicines and Poisons Regulation branch.

It is anticipated that this form will be used predominantly by pharmacists but it may be used by other registered health practitioners.

Notifications and submissions will be received and assessed by authorized officers of Medicines and Poisons Regulation - Tel: 1300 364 545 or via email dpcs@dhhs.vic.gov.au

NOTE: Once you have completed and submitted this form, you will be able to download a PDF copy of the completed form for your records.

Health Practitioner Details

Notifications and records to be submitted to Medicines and Poisons Regulation

Fields marked with * are required

Health Practitioner Details

Title *

Given Name *

Surname *

Type of Practitioner *

AHPRA Registration Number *

Pharmacy/Clinic Name *

Street Address *

Suburb *

State

Postcode *

Business phone *

Fax Number

Email address of pharmacy/clinic

*OR

Preferred email address to facilitate further contact if such communication should not be directed to the pharmacy/clinic

Notification or submission details

Notifications and records to be submitted to Medicines and Poisons Regulation

Fields marked with * are required

Nature of Notification or Submission

Please select one of the following:

Notification of apparently excessive prescribing, as required under section 32A of the Drugs Poisons and Controlled Substances Act 1981

Summary and explanation of matters of concern *

Prescriber Details (of the principal prescriber)

Title *

Given Name *

Surname *

Type of Prescriber *

Prescriber Number and/or AHPRA Registration Number *

Practice Name

Street Address *

Suburb *

State *

Postcode *

Business Phone *

Fax Number

Summary of relevant communications with the principal prescriber (or others) *

Patient’s name and address plus date of birth (if known) *

You are required to provide a copy of relevant dispensing records for a period of at least three to six months (add multiple files individually):

File:

I will send the records by post

Submission of records, as required under regulation 109(5) of the Drugs Poisons and Controlled Substances Regulations 2017

Name of the authorized officer to whom this submission is directed *

Additional information or clarification (as required)

You are required to provide a copy of relevant dispensing records for the requested period (add multiple files individually):

File:

I will send the records by post

Declaration

Notifications and records to be submitted to Medicines and Poisons Regulation

Fields marked with * are required

Declaration

I, , confirm the information I provided in this notification is true and complete to the best of my knowledge.

By ticking this checkbox I confirm that I have read and understood the above statement. *

Date

Privacy Statement

It is a requirement of the Drugs, Poisons and Controlled Substances Act 1981 and the Drugs, Poisons and Controlled Substances Regulations 2017 that the information set out in this form is provided to the Department of Health & Human Services to meet statutory notification requirements; to provide information for assessing the prevalence and nature of fraudulent prescriptions; and to alert pharmacists about recent fraudulent prescriptions. The collection, use and disclosure of the information provided will be in accordance with the law, including the provisions of the Health Records Act 2001. The information collected may be disclosed to health practitioners practising in the following health professions: medical, nursing and midwifery and pharmacy, when necessary to facilitate coordination of a patient's drug treatment and safe prescribing of drugs. For example, it may be necessary to disclose this information when another health practitioner applies for a permit or is considering prescribing a drug of dependence. The notification may not be processed if all information requested on the form is not completed.

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Getting Started

Health Practitioner Details

Health Practitioner Details

Notification or submission details

Declaration

Declaration

Privacy Statement