Authority for Authorised Pharmacist(s) to sign ... - Medicare website

Authority for Authorised
Pharmacist(s) to sign claim forms
on behalf of Approved Pharmacist(s)
When to use this form
Complete this form if you are an approved pharmacist(s) and business
owner(s) of a pharmacy approved under Section 90 of the
National Health Act 1953.
Use this form to:
• authorise a pharmacist(s) to sign pharmaceutical benefit claim
forms and endorse pharmaceutical benefit prescriptions on
behalf of the approved pharmacist(s).
• request removal of previously authorised pharmacist(s).
For more information
For more information go to our website
humanservices.gov.au/healthprofessionals > PBS > become an
approved supplier > pharmacist or for assistance completing this
form call 132 290 Monday to Friday, between 8.30 am and 5.00 pm,
local time.
Note: Call charges apply – calls from mobile phones may be charged
at a higher rate.
Filling in this form
• Please use black or blue pen
• Print in BLOCK LETTERS
• Mark boxes like this with a ✓ or 7
Approved pharmacist 3
Dr Mr Mrs Miss Ms Other
Family name
First given name
Approved pharmacist 4
Dr Mr Mrs Miss Ms Other
Family name
First given name
Approved premises
If there are more than 4 approved pharmacists attach a
separate sheet with details.
Returning your form
Check that you have answered all the questions you need to answer
and that you have signed and dated this form.
Scan and email the completed form and any attachments to:
nsw.pbs.approval.clerk@humanservices.gov.au
or
for more information contact a Pharmacy Program Officer on 132 290.
Approved pharmacist(s)
2 PBS approval number
3 Address of pharmacy premises
Town/Suburb
Postcode
1 Give details of all approved pharmacists and/or business owners
Approved pharmacist 1
Dr Mr Mrs Miss Ms Other
Family name
First given name
Name(s) of authorised pharmacist(s)
4 Give details of all authorised pharmacists
Authorised pharmacist 1
Dr Mr Mrs Miss Ms Other
Family name
First given name
Approved pharmacist 2
Dr Mr Mrs Miss Ms Other
Family name
First given name
Registration number
Signature
-
4042.1305 1 of 2

Authorised pharmacist 2
Dr Mr Mrs Miss Ms Other
Family name
First given name
Registration number
Signature
-
Authorised pharmacist 3
Dr Mr Mrs Miss Ms Other
Family name
First given name
Registration number
Signature
-
Authorised pharmacist 4
Dr Mr Mrs Miss Ms Other
Family name
First given name
Registration number
Authorised pharmacist name
Declaration
If there are more than 4 previously authorised
pharmacists attach a separate sheet with details.
6 I/we declare that:
• the information provided in this form is complete and correct.
• the dispensing of drugs and medicinal preparations will be
performed under the direct supervision of a pharmacist at the
premises specified above, in accordance with Part VII of the
National Health Act 1953 (the Act) and the regulation made
under the Act.
I/we understand that:
• giving false or misleading information is a serious offence.
I/we authorise the pharmacist(s) whose signature(s) appear
above, to:
• sign pharmaceutical benefit claim forms, and
• endorse pharmaceutical benefit prescriptions on my/our behalf.
Approved pharmacist 1
Signature of approved pharmacist 1
-
Date / /
Approved pharmacist 2
Signature of approved pharmacist 2
-
Date / /
Approved pharmacist 3
Signature of approved pharmacist 3
-
Date / /
Signature
-
If there are more than 4 authorised pharmacists attach
a separate sheet with details.
Previously authorised pharmacists
5 Please list here any previously authorised pharmacists you wish
to cancel
Authorised pharmacist name
Authorised pharmacist name
Authorised pharmacist name
4042.1305 2 of 2
Approved pharmacist 4
Signature of approved pharmacist 4
-
Date / /
If more than 4 approved pharmacists signatures are
required attach a separate sheet with details.
Privacy notice
Your personal information is protected by law, including the
Privacy Act 1988, and is collected for a Social Security, Family
Assistance, Medicare, Child Support and CRS purpose, depending
on the service or payment concerned. This information may be
required by law or collected voluntarily when you apply for services or
payments.
Your information is used for the assessment and administration of
payments and services and may also be used within Human Services,
or disclosed to other parties or agencies, where you have provided
consent or it is required or authorised by law.
You can get more information about privacy by going to our website
humanservices.gov.au/privacy or requesting a copy of the full
privacy policy at any of our Service Centres.