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Getting Started

Notification of lost and stolen prescriptions by health practitioners other than pharmacists
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Who should complete this form?
Clinics and prescribers are requested to provide details to the Medicines and Poisons Regulation branch in relation to lost or stolen prescription pads or pages so that pharmacists can be alerted about the possibility of forged prescriptions being presented on pre-printed stationery.

Note: If you have reason to believe you know the identity of the person who stole the prescriptions, please notify Victoria Police as a matter of urgency.

Note: Pharmacists wishing to report a forged or fraudulently altered prescription should use the form Notification of forged or altered prescription (i.e. not this one).

Note: Members of the public should not use this form to notify the department about prescriptions or repeat prescriptions that have been lost, destroyed or misplaced. Such matters should be reported to Victoria Police if the person responsible for a theft can be identified.

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

Details of Notifier

Notification of lost and stolen prescriptions by health practitioners other than pharmacists
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Details of Notifier

Prescription Details

Notification of lost and stolen prescriptions by health practitioners other than pharmacists
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Description of lost or stolen stationery
Please select one of the following:
Attach a copy of the pre-printed prescriber and clinic information from the FRONT of similar prescriptions.
File:

Prescriber Details (as pre-printed on the front of the prescription)

Relevant Details (as pre-printed on the front of the prescription)

Attach a copy of the pre-printed hospital information from the FRONT of similar hospital prescriptions.
File:

Hospital Details (as pre-printed on the front of the hospital prescription)

Attach a copy of the pre-printed clinic information on the REAR of similar pages for computer generated prescriptions.
File:

Relevant Details as pre-printed on the REAR of the computer-generated prescription pages

Privacy Statement

Notification of lost and stolen prescriptions by health practitioners other than pharmacists
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Privacy Statement

The information set out in this form is provided to the Department of Health & Human Services 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.
Department of Health & Human Services