spacer State Government Victoria Australia Department of Health header
Victorian Government Health Information header
Victorian Government Website (Victoria the place to be)
spacer
spacer Health Home
Main A to Z Index | Site Map | About Health | Links  
Commonwealth/State Highly Specialised Drugs Program banner
>>contact

Appendix 5: Certification by Prescribing Doctor

The certification form must contain the following elements:

  • patient's name
  • patient's UR number
  • patient's Medicare number (or other proof of eligibility to receive a pharmaceutical benefit)
  • drug name
  • Pharmaceutical Benefits Advisory Committee approved clinical indications for the specific drug
  • a statement from the prescriber to the effect:

    "I certify that the above named patient meets the Pharmaceutical Benefits Advisory Committee's criteria for the prescription of the Drug name ."

  • prescribing doctor's signature
  • prescribing doctor's name & title
  • date
  • In the case of GP's authorised to prescribe HIV/AIDs drugs the additional information:

  • provider number; and
  • practice address and phone number.
  • Click to access a Generic Certification by Prescribing Doctor form or you may wish to design your own form that contains the above elements.

    Return to Top


    Contact: Michael Furey Tel (03) 9096 2506 Fax (03) 9096 9205

    Last updated: 30 April, 2008
    This web site is managed and authorised by the Ambulance & Acute Programs Section of the Metropolitan Health and Aged Care Services Division of the Victorian State Government, Department of Health, Australia

    Copyright | Disclaimer | Privacy Statement | State Government of Victoria Home | Download Help

    For general enquiries to the Department of Health telephone 61 3 90960000