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 approval as a supplier of pharmacotherapies (48kb, pdf)

Self-assessment for compliance with key requirements.

Self-Assessment Form for Pharmacists Opioid-Replacement Therapy September 2013

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: or fax: 1300 360 830).

Pharmacotherapy dispensing support program tax invoice


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.