Drugs of Dependence Unit
Phone: 1300 652 584
AUTHORITY APPLICATION

TO PRESCRIBE OR SUPPLY A DRUG OF DEPENDENCE FOR A PATIENT WHO HAS RECEIVED TREATMENT FOR A
PERIOD EXCEEDING TWO MONTHS (Section 18A, Controlled Substances Act)

NEW c	RENEWAL  c	AMENDMENT  c

 SECTION A: PRESCRIBER DETAILS 	

Surname: 					First Name: 

Address: 					Phone: 				Fax / Email: 

Prescriber #: 					AHPRA#: 			Specialty: 

 SECTION B: PATIENT DETAILS 	

Surname: 				First Name: 			Date of Birth: 		
Gender:
Address: 

 SECTION C: TREATMENT DETAILS 	

Medical condition for which drugs of dependence are prescribed:

Drug(s) of dependence prescribed: 

Proposed dose and frequency: 

Expected maximum dose and frequency: 

Date drug(s) commenced: 

Other drug use / dependency: eg Amphetamines/Benzodiazepines/Alcohol/illicit drugs

Drug/s:									frequency:

Comments: 
Please indicate if additional reports are attached: c

If drug ceased date discontinued: 			Reason: 

Is it your opinion that the life expectancy of this patient is less than 12 months?	Yes c
(Notification required only if ≤12 months, provided Schedule 8 prescriptions are endorsed “NPCP” or “Notified Palliative Care Patient”)
SECTION D: PRESCRIBER DECLARATION 	

I have explained the nature of treatment and the potential side effects to the patient, and he/she has consented to the treatment. I confirm that the information I have provided in this application is true, accurate and complete to the best of my knowledge. I understand that my application may not be processed if all the information requested on this form is not completed. 

 Signature: 									 Date: 

Privacy Statement: The information set out in this form is required by the Minister responsible for the Controlled Substances Act 1984 to consider granting an authority to prescribe a Schedule 8 drug as required under the law. Personal and health information is protected by the Privacy Act 1988 and can only be collected, used and disclosed for authorised purposes. Information provided in this form will be included in the patient’s ScriptCheckSA record and will be accessible to other prescribers and pharmacists treating the patient to support their clinical decision making. Information (including personal information) must not be accessed, used or disclosed for any purpose, other than as allowed by the Controlled Substances Act 1984 and the Controlled Substances (Poisons) Regulation 2011. Penalties may apply for unauthorised access, use or disclosure of information in ScriptCheckSA. For further advice or clarification, please email HealthDrugsofDependenceUnit@sa.gov.au