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Getting Started

Notification of forged or altered prescription by pharmacists
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Who should complete this form?
Regulation 69 of the Drugs, Poisons and Controlled Substances Regulations 2017 requires a pharmacist to notify Victoria Police and the Department of Health & Human Services when the pharmacist has reason to believe that a person has obtained or attempted to obtain a prescription medicine by false representation (e.g. a forged or fraudulently altered prescription).

Not notifying the authorities is an offence; it is not acceptable for a pharmacist to assume that the department has been notified by the purported prescriber or another pharmacy.

When reporting forged or altered prescriptions to police, please ensure that police are informed when the offender can be identified or when there is evidence that might assist in identification, e.g. digital image of the offender or the licence plate number

Notifications will be processed by Medicines and Poisons Regulation branch - Tel: 1300 364 545 or via email dpcs@dhhs.vic.gov.au

NOTE: Once you have completed and submitted this form online, you will receive a confirmation email that your completed form has been received by the department. There will not be any additional communication unless further information is required by the department.

Pharmacist Details

Notification of forged or altered prescription by pharmacists
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Pharmacist Details

Prescription Details

Notification of forged or altered prescription by pharmacists
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Prescriber Details (on the face of the prescription)

Nature of Forgery or Alteration

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Was the medication supplied?
Can you provide a copy of the forged or altered prescription?
Please attach a scanned copy of the forged or altered prescription.

Attachment

Copy of forged/altered prescription
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Any Additional Information (optional)

Declaration

Notification of forged or altered prescription by pharmacists
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Declaration

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

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.
Department of Health & Human Services