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

• Claim Template: Staged Supply Services + Patient Registration (xlsx - 19 KB)
• Claim Template: Staged Supply Follow Up (xlsx - 18 KB) – NEW
• Staged Supply Patient Information and Consent (pdf - 162 KB)

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

• RMMR Prior Approval Request for Pharmacist Only Review (pdf - 193 KB)
• Claim Template: RMMR Services (xlsx - 18 KB)
• RMMR Service Agreement example (doc - 104 KB)
• RMMR QUM Service Agreement example (doc - 120 KB)

Rural Support Programs

Continuing Professional Education

• Application Form
• Travel Log Book Template (pdf - 85 KB)

Emergency Locum Service

• Application Form

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

•  Application Form
• Travel Log Book Template (pdf - 85 KB)

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

• Rural Pharmacy Scholarship Agreement (pdf - 71 KB)
• Rural Pharmacy Scholarship Blank Statutory Declaration (pdf - 65 KB)
• Rural Pharmacy Scholarship Statutory Declaration (pdf - 65 KB)

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 - 223 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)