It is a requirement of the Drugs, Poisons and Controlled Substances Act 1981 (the Act) that the information set out in this form is provided to the Department of Health & Human Services to meet statutory notification requirements, and for the issuing of permits as required under the Act. 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 the 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 application may not be processed if all information requested on the form is not completed.