Forms

Forms for prescribers

Application for approval as a pharmacotherapy prescriber

Use the following form to apply for approval to become a pharmacotherapy prescriber following completion of the required training program.

Application for approval as a pharmacotherapy prescriber (49kb, pdf)
Permit applications

With some exceptions*, all medical practitioners must have a current permit to treat a patient for opioid dependence with methadone or buprenorphine. Permits are issued per-patient.

Application for a permit to treat an opioid dependent person with methadone or buprenorphine (62kb, pdf, complete and return by fax or mail) Application for a permit to treat an opioid dependent person with methadone or buprenorphine (Smartform, complete and return online)
* Exceptions include patients being treated in prisons or residential aged care services or as hospital inpatients. Refer to the Department of Health key legislative requirements for details. Note that an excepted patient must still be notified to the Department of Health using the same form.
Notifications

Use the following forms to notify the Department of Health of a patient's drug dependence or to notify the department of the termination of a patient's participation in the methadone or buprenorphine program.

Notification of drug dependent person (to submit via fax or post) Notification of drug dependent person (SmartForm – to submit online)  Notification of termination of methadone or buprenorphine program (to submit via fax or post) Notification of termination of methadone or buprenorphine program (SmartForm – to submit online) 

Forms for pharmacists

Application for approval as a pharmacotherapy supplier

Pharmacists may use the following form to apply for approval to become a pharmacotherapy supplier following completion of the required training program.

Application for permission to supply pharmacotherapies in Victoria (156kb, pdf)
Self-assessment for compliance with key requirements.
Self-Assessment Form for Pharmacists Opioid-Replacement Therapy
Dispensing support tax invoice template

If a client is eligible for pharmacotherapy dispensing support, the Department of Health issues a letter to the dosing pharmacy confirming details of dispensing support. If a client who is eligible for dispensing support has transferred to your pharmacy, but you have not received the letter from the department, the prescriber may need to notify the department in writing of the change of pharmacy details and include the date of commencement at your pharmacy (by email: dpcs@health.vic.gov.au or fax: 1300 360 830).

Pharmacotherapy dispensing support program tax invoice

Notes.

All links provided are direct links to the Victorian Department of Health original documents unless specified. A list of all Department pharmacotherapy forms can be found here. health.vic.gov.au/dpcs/pharm.htm