Request for Ministerial Approval
Approval to supply pharmaceutical benefits at particular premises (subsection 90A(2) of the National Health Act 1953)
Please note:
• A request can only be made if an application for approval under section 90 of the National Health Act 1953 has been rejected by
the Delegate of the Secretary of the Department of Health (the Secretary’s Delegate) following a recommendation that it not be
approved because it did not meet the requirements of rules determined by the Minister for Health (the Minister) under
section 99L of that Act (the Pharmacy Location Rules).
• A request must not be made if the decision of the Secretary’s Delegate is the subject of proceedings before the Administrative
Appeals Tribunal or Federal Court and the proceedings have not been discontinued, withdrawn, dismissed or otherwise finally
determined.
• Giving false or misleading information is a serious offence.
A: Person/s making request
I/We request the Minister to exercise the discretionary power under subsection 90A(2) of the National Health Act 1953 to approve
the pharmacist/s to supply of pharmaceutical benefits at premises described in Section C of this form.
Family name/company name (1)
Given name (1)
Family name/company name (2)
Given name (2)
Family name/company name (3)
Given name (3)
Family name/company name (4)
Given name (4)
If this request is being made on behalf of a company, friendly society, body corporate, trust or the like, evidence must be attached
to this form which shows that the person/s named below is/are authorised to make this request.
Daytime Phone No.
B: Contact details
Postal
address
(
)
State/Territory
Postcode
Email
Please indicate how you would like to receive all
future correspondence concerning this request:
in hard copy (by mail)
electronically (please ensure an email address is provided above)
C: Details of the rejected application by the Secretary’s Delegate, under section 90 of the National Health Act 1953
Application no.
Notification of the decision of the Secretary’s Delegate not
to grant approval of my/our application by notice dated:
/
My/Our application for approval was in respect of premises at:
State/Territory
My/Our application sought to:
Postcode
establish a new pharmacy approval
relocate an existing pharmacy approval (please complete Section D)
A copy of the decision of the Secretary’s Delegate, rejecting your application, must be attached to this request.
Is the decision of the Secretary’s Delegate (at the date of this request) the subject of a
proceeding before the Administrative Appeals Tribunal or a Federal Court?
Yes
No
/
D: Current approval (only to be completed if this request relates to the relocation of an existing pharmacy approval)
I/We request the cancellation of my/our approval in respect of the premises at the address below, under subsection 98(1) of the
National Health Act 1953, if approval is granted under section 90A of that Act to the person/s described in Section A.
Current approval no.
Current
pharmacy
address
State/Territory
Postcode
Full name/s of person/s approved in respect of the address above:
(1)
(3)
(2)
(4)
(all current approved pharmacist/s or person/s acting on behalf of a friendly society or body corporate must be named)
Signed (1)
Date
/
/
Signed (3)
Date
/
/
Signed (2)
Date
/
/
Signed (4)
Date
/
/
(all current approved pharmacist/s must sign and date this section)
E: State/Territory Registration details
I/We are pharmacist/s registered under the law of the State/Territory of:
Registration number/s:
(1)
(2)
(3)
(4)
F: State/Territory Pharmacy Board Approval
Do you have current State Pharmacy Board approval in which the premise is situated, to carry on business?
If yes, please attach copy.
Yes
No
Subsection 90A(6): The power under subsection (2) does not authorise the Minister to approve a pharmacist for the purpose of
supplying pharmaceutical benefits at particular premises at which the pharmacist is not permitted, under the law of the State or
Territory in which the premises are situated, to carry on business.
G: Declaration (to be completed by person/s making this request, named in Section A)
I/We declare that, to the best of my/our knowledge and belief, the information contained in this form, and in the attachments to
this form, is true and correct. I/We also declare that I/we are willing to supply pharmaceutical benefits at premises described in
Section D in accordance with Part VII of the National Health Act 1953 and the Regulations made under that Act.
Signed (1)
Date
/
/
Signed (3)
Date
/
/
Signed (2)
Date
/
/
Signed (4)
Date
/
/
For lodgement information:

go to http://www.health.gov.au/internet/main/publishing.nsf/Content/pharmacy-ministerialdiscretion

contact the Ministerial Discretion Hotline on (02) 6289 2425 or email [email protected]
Privacy note: This personal information about you is being collected by the Department of Health (the Department) for use in assessing your request for the
exercise of the Minister’s discretion under section 90A of the National Health Act 1953 (the Act). The collection of this information is authorised by the Act. If you
do not provide all the information, the Minister may not be able to consider your request for the exercise of the Minister’s discretion. The Department will disclose
your personal information to the Minister and the Department of Human Services. The Department has an Australian Privacy Principle (APP) policy which you can
read at www.health.gov.au/internet/main/publishing.nsf/content/privacy-policy. You can obtain a copy of the APP privacy policy by contacting the Department
using the contact details set out above. The APP privacy policy contains information about how you may access the personal information the Department holds
about you and how you can seek correction of it; and how you may complain about a breach of the APPs. The Department is unlikely to disclose your personal
information to overseas recipients.
04/2014