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Notification of Change in PBS Number


Notification of Change in PBS Number

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									                                                                                            LEVEL 2, 15 NATIONAL CIRCUIT BARTON ACT 2600
                                                                                          PO BOX 7036 CANBERRA BUSINESS CENTRE ACT 2610
                                                                                                        F 02 6270 1885 HELPLINE 1300 363340
                                                                                           E-MAIL * INTERNET www.qcpp com

                                                                                                            CONTACT ID#__________________

                               Notification of Change in PBS Number
Reason for PBS Change (please tick)

           a. Relocation of Pharmacy                                b. Change in Partnership Arrangements

           c. Transfer of Ownership                                 d. Other (specify):

Pharmacy Details

 Pharmacy Name:
 Contact Person:
 Pharmacy Address:
 City/Town:                                                     State:                       Postcode:
 Phone Number:                                                  Fax Number:
 ABN:                                                           Marketing Group:
 Guild Member? YES / NO                                         Guild Member Number:
 Name(s) of Proprietors:

PBS Details

 Old PBS Approval Number:
 New PBS Approval Number:                                                                    Date Approval Issued:

For Transfer of Ownership Pharmacies Only

1. Date of Transfer of Ownership:                                   /            /

2. Do you intend to continue with the Quality Care Pharmacy Program? YES / NO

Note: To maintain your QCPP accreditation status after a transfer of ownership it is a requirement of the 1st edition
that the staff member who signed the Standards is still employed within the pharmacy. If the pharmacist, or
pharmacy staff, who signed the Standards is no longer employed after a transfer of ownership the pharmacy will
need to undertake an external reassessment within six months to maintain its QCPP accreditation.

3. Will you be undergoing a reassessment? YES / NO

If your pharmacy is successful in becoming reaccredited after reassessment it will be eligible to receive an annual
Quality Maintenance Allowance of between $3000 and $5000.

Proprietor’s Signature:    ...................................................

  The QCPP is wholly committed to upholding the National Privacy Principles established under the Privacy Act 1998
 (Commonwealth) and as such will safeguard the information. You have the right to access your personal information. We will
only provide information to organisations for the purposes related to the administration of the QCPP. However your information
may also be shared with The Pharmacy Guild of Australia. If you have any questions about your privacy rights please contact the
                                                QCP Division on 1300 363 340.

                      I would not like my information shared with The Pharmacy Guild of Australia
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