Queensland Health
Medicines and Poisons Act 2019
MPA-75,78,&82:PAMM
Version 3 - 04/2024
Initial, amendment or renewal application for a prescribing approval for
(Schedule 8) psychostimulants under the Medicines and Poisons Act 2019
Page 1 of 3
Privacy statement – please read carefully
Personal information collected by Queensland Health is handled in accordance with the
Information Privacy Act 2009
. Queensland Health is collecting your
personal information with your consent for the purpose of deciding an application under the
Medicines and Poisons Act 2019
, including by ensuringthat
health risks arising from the use of regulated substances. are appropriately managed. All personal information will be securely stored and only accessible by
Queensland Health. Your personal information will not be disclosed to any other third parties without consent unless the disclosure is authorised or required
by law. For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal
information, please see our website at www.health.qld.gov.au/ global/ privacy.
PLEASE CHECK QSCRIPT TO VIEW THE OUTCOME OF YOUR APPLICATION
Application type
Initial application for prescribing approval to treat a patient with S8 psychostimulant medicine
Application to amend an approval to treat a patient with S8
psychostimulant medicine
Please provide details of amendment in Section 7
Approval
number
Application to renew an approval to treat a patient with S8
psychostimulant medicine
Approval
number
Section 1 – Prescriber details (applicant)
Provide details of the person seeking the prescribing approval
Title Given name/s Surname
Occupation AHPRA Registration No
Practice name
Practice address
Town/Suburb State P/C
Work phone Mobile phone
Work email address
Do you have any restrictions on your professional registration (e.g. conditions or
undertakings) that would prevent you from prescribing the medicines you are applying
for a prescribing approval for?
Yes No
If yes, provide further details of the restrictions on your professional registration:
Section 2 – Patient details
Provide details of the patient:
Please provide given name and surname as per
medicare card
Title Given name/s Surname
Alternative identities: Please provide details of any alternative (previous or current) identities/names used by the patient
Gender Male Female
Other DOB
Street address
Town/Suburb State P/C
Queensland Health
Medicines and Poisons Act 2019
MPA-75,78,&82:PAMM
Version 3 - 04/2024
Initial, amendment or renewal application for a prescribing approval for
(Schedule 8) psychostimulants under the Medicines and Poisons Act 2019
Page 2 of 3
Section 3 – Diagnosis for treatment with Schedule 8 psychostimulant medicines
Attention Deficit Disorder — Adult (ADD/ADHD)
Attention Deficit Disorder — Child (ADD/ADHD < 4 years)
Nurse Practitioner treating a Child for ADD/ADHD (>4 years and <18 years)
NOTE – approval not required for medical practitioners prescribing within dosage limits
Idiopathic hypersomnolence (not including narcolepsy)
Binge eating disorder (lisdexamfetamine only)
Treatment resistant depression
Palliative care
Other:
(Please provide evidence of diagnosis, and
treatment plan made by supporting specialist)
Section 4 – S8 psychostimulant medicine proposed to be prescribed under this approval
Dexamfetamine Maximum daily dose: mg/day
Lisdexamfetamine Maximum daily dose: mg/day
Methylphenidate Maximum daily dose: mg/day
Section 5 – Supporting specialist details – S8 psychostimulant treatment
Please provide details of the relevant specialist that made the diagnosis in Section
3 AND the treatment proposed in Section 4.
Include letter of referral from relevant specialist supporting diagnosis and treatment plan.
• For applications to treat an adult (≥ 18 years) with ADD/ADHD, the relevant specialist is a psychiatrist
• For applications to treat a child with ADD/ADHD the relevant specialist is a paediatrician or psychiatrist
Title Given name/s Surname
Medical specialty AHPRA Registration No
Work phone Work email address
Name of location where
specialist practices:
Date of last review by
relevant specialist
Street
Address
Town
/Suburb
State P/C
I confirm that I am applying to prescribe the medicine(s) in Section 4 in accordance with a
treatment plan for the patient named in the application, made by the specialist named
above.
Yes
Queensland Health
Medicines and Poisons Act 2019
MPA-75,78,&82:PAMM
Version 3 - 04/2024
Initial, amendment or renewal application for a prescribing approval for
(Schedule 8) psychostimulants under the Medicines and Poisons Act 2019
Page 3 of 3
Section 6 – Duration of the prescribing approval (s.69 MPA)
Please specify the requested term for the prescribing approval. Applicants should note that prescribing approvals will
not usually be granted for more than two (2) years.
Please specify the term for the prescribing approval being sought:
2 years Another term or end date, please specify:
Section 7 – Additional information and attachments
Provide any additional information to support your application (e.g. if applying to amend a prescribing approval,
detail what you are seeking to have amended).
Section 8 – Consent and Declaration
By making this application:
I consent to Queensland Health collecting, using and disclosing my personal information for the purpose
of determining this application and any matters relevant to this prescribing approval
I consent to Queensland Health making enquiries of, and exchanging information with, the authorities of
any Australian state or territory, or of the Commonwealth, regarding any matters relevant to this
application (which may include a criminal history check). If relevant information cannot be obtained from
other entities, Queensland Health will determine the application on the information available.
I
declare that, to the best of my knowledge, all information provided in and with this application form is true
and correct in every detail.
I
understand that if anything has been stated in this application form, or in an attachment provided with
this application, that is false or misleading, any substance authority granted may be suspended or
cancelled.
Signature
Full name
Date
APPLICATIONS FOR ALL NON-QOTP PRESCRIBING APPROVALS CAN BE SUBMITTED TO:
The Chief Executive, Queensland Health
c/ o Medicines Approvals and Regulation Unit (MARU)
medicines.applications@health.qld.gov.au
PLEASE CHECK QSCRIPT TO VIEW THE OUTCOME OF YOUR APPLICATION
CLEAR FORM
