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

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.
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