By completing this form, you acknowledge that you are providing the personal and health information to the Department of Health, Victoria (the Department) for the purpose of notifying the Department of your reason to believe a patient is a drug-dependent person.

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 patient's health information:
•will be used and disclosed for the purposes of assessing the permit application or meeting notification requirements;•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.

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.