Forms and Templates
6CPA Registration and Claiming Portal
- 6CPA Program Registration Form (pdf - 116 KB)
- 6CPA Exceptional Circumstances Request Form (pdf - 1 MB) – NEW
- Claim Template: DAA Basic Service Provision (xlsx - 54 KB) – NEW
- Claim Template: HMR Services (xlsx - 19 KB)
- Claim Template: MedsCheck and Diabetes MedsCheck Services (xlsx - 14 KB) – NEW
- Claim Template: RMMR Services (xlsx - 18 KB)
- Claim Template: Staged Supply Services + Patient Registration (xlsx - 19 KB)
- Claim Template: Staged Supply Follow Up (xlsx - 18 KB) – NEW
- Excel Template: Patient Medication Profile (xlsx - 11 KB) – NEW
Medication Adherence Programs
Dose Administration Aids
- Claim Template: DAA Basic Service Provision (xlsx - 54 KB) – NEW
- Calculating your DAA Claim - worksheet (pdf - 108 KB)
- Dose Administration Aids (DAA) Patient Information and Consent (pdf - 162 KB)
- DAA Patient Registration - Initial Interview Form (pdf - 111 KB) – NEW
- Excel Template: Patient Medication Profile (xlsx - 11 KB) – NEW
Staged Supply
Medication Management Programs
Home Medicines Review
- 6CPA Patient Privacy Notification (pdf - 144 KB)
- Prior Approval Request for HMR Interview Outside the Patient's Home (pdf - 157 KB)
- Prior Approval Request for HMR Interview conducted by Registered Pharmacist (pdf - 157 KB)
- Claim Template: HMR Services (xlsx - 19 KB)
- HMR Rural Loading Allowance Log Book (pdf - 82 KB)
MedsCheck and Diabetes MedsCheck
- Regular MedsCheck Patient Information and Consent (pdf - 163 KB) – New
- Diabetes MedsCheck Patient Information and Consent (pdf - 165 KB) – New
- MedsCheck and Diabetes MedsCheck Patient Registration - Initial Interview Form (pdf - 109 KB) – New
- Claim Template: MedsCheck and Diabetes MedsCheck Services (xlsx - 14 KB) – New
- Excel Template: Patient Medication Profile (xlsx - 11 KB) – New
- Claim Template: MedsCheck and Diabetes MedsCheck Services (Pre 1 Feb 2018) (xlsx - 18 KB)
Residential Medication Management Reviews
Rural Support Programs
Continuing Professional Education
Emergency Locum Service
Intern Incentive Allowance for Rural Pharmacies
- Application Form
- Pharmacist Mid Placement Report
- Pharmacist End Placement Report
- Pharmacy Intern End Placement Feedback Report
Intern Incentive Allowance for Rural Pharmacies – Extension Program
- IIARP-EP Application Form (pdf - 166 KB)
- IIARP-EP Pharmacist Mid Placement Report (pdf - 139 KB)
- IIARP-EP Pharmacist End Placement Report (pdf - 142 KB)
- IIARP-EP Newly Registered Pharmacists End Placement Report (pdf - 138 KB)
Rural Intern Training Allowance
Rural Pharmacy Maintenance Allowance
- Rural Pharmacy Maintenance Allowance Application (pdf - 158 KB)
- Rural Pharmacy Maintenance Allowance Certification Statement (pdf - 149 KB)
Rural Pharmacy Scholarship Scheme
Aboriginal and Torres Strait Islander Specific Programs
Aboriginal and Torres Strait Islander Pharmacy Assistant Traineeship Scheme
- Application Form
- Pharmacist Mid Placement Report
- Pharmacist End Placement Report
- Pharmacy Assistant End Placement Report
- Aboriginal and Torres Strait Islander Pharmacy Assistant Traineeship Self Identification Form (pdf - 142 KB)
Aboriginal and Torres Strait Islander Pharmacy Scholarship Scheme
- Beginning and End of Year Details
- Pharmacy Scholarship Agreement (pdf - 116 KB)
- Blank Statutory Declaration (pdf - 111 KB)
- Application Statutory Declaration (pdf - 111 KB)
- Aboriginal and Torres Strait Islander Pharmacy Assistant Traineeship Self Identification Form (pdf - 142 KB)
- Mentor Report and Details Form
QUMAX – Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander People
- Form A – QUMAX DAA Agreement (pdf - 229 KB)
- Form B – Banking details and RCTI Agreement (pdf - 236 KB)
- QUMAX Pharmacies Reporting Form (pdf - 204 KB)
S100 Pharmacy Support Allowance
- S100 Form A – Application for Section 100 Support Allowance (New and Renewals) (pdf - 183 KB)
- S100 Form B – Certification of Continued Support Services (pdf - 134 KB)
- S100 Needs Assessment Template (pdf - 735 KB)
- S100 Work Plan Template (pdf - 805 KB)
- S100 RCTI Agreement for Community Pharmacy (pdf - 142 KB)