OTP PhIS Declaration - November 2025 to April 2026

OTP PhIS Declaration November 2025 to April 2026 inclusive

HOW INFORMATION ON THIS FORM MAY BE USED

Information on this form may be used to support referrals and access to the OTP. The NSW Ministry of Health may make this information publicly available to assist in service planning and delivery. We assume that your pharmacy currently provides OTP services as declared on the form and consent to this information being shared publicly on the NSW Health website. The information shared may include the pharmacy name and location and whether the pharmacy provides long acting injectable buprenorphine (LAIB) administration services.

Please note the NSW Ministry of Health and NSW Branch of The Guild will conduct random audits of the following information provided and all records relating to pharmacotherapy dosing to ensure compliance with the Poisons and Therapeutic Goods Act 1966 and Poisons and Therapeutic Goods Regulation 2008 and records related to undertaking OTP Self- Audits and LAIB administration.

SECTION 1: PHARMACY DETAILS

Pharmacy Name *

Address *

Street address *Street address line 2

City *

State *

Postcode *

Phone Number *

Email *

Pharmacy's Local Health District

Please select your pharmacy's LHD from the Drop Down List

Select LHD *

SECTION 2 : OTP PATIENT DECLARATION

Please enter the number of unique patients dosed for at least 2 months consecutively within the reporting period for each OTP Medication. Note: You may include LAIB dispensed from your pharmacy and administered at another a clinic.

Please use numbers for this field. If no patients enter 0

METHADONE/BIODONE *

BUPRENORPHINE/NALOXONE *

BUPRENORPHINE *

DEPOT BUPRENORPHINE *

TOTAL number of patients dosed for at least 2 months consecutively during the reporting period *

SECTION 3A: LAIB ADMINISTRATION

Does your pharmacy currently administer LAIB? *

Yes (If commenced after 1 July 2024 go to Section 3B)No (Go to Section 4)Not at the moment, but interested (Go to Section 4)

LAIB Administration Incentive

Pharmacies registered for the OTP Pharmacy Incentive Scheme who have begun administering Depot Buprenorphine on the pharmacy premises AFTER 1 July 2024 are able to access an incentive payment of $100 + GST for each of the first 10 administrations. Pharmacies who administered Depot Buprenorphine prior to 1 July 2024 cannot claim this incentive.

SECTION 3B: COMMENCEMENT OF LAIB ADMINISTRATION DECLARATION

I declare that this pharmacy has not administered Depot Buprenorphine prior to 1 July 2024 and that since that date, the following number of Depot Buprenorphine medicines have been administered by a pharmacist to OTP patients on the pharmacy premises.

Buvidal Weekly

Buvidal Monthly

Sublocade

Total LAIB Administered

SECTION 4: OTP PATIENT CAPACITY

To assist the NSW Ministry of Health in understanding pharmacy capacity for the provision of OTP and identifying areas of need, please rate your pharmacy's capacity to accept additional OTP patients.

What is your pharmacy's willingness to dose additional patients on OTP? *

High - My pharmacy is able to accept more than 20 additional OTP patientsMedium - My pharmacy is able to accept an additional 5 to 20 OTP patientsLow - My pharmacy is able to accept less than 5 additional OTP patientsNone - My pharmacy is unable to accept additional OTP patients

SECTION 5: OTP MANAGEMENT SOFTWARE

Does your pharmacy use OTP Management Software? *

YesNo

SECTION 6: OTP PHARMACY SELF AUDIT DECLARATION

Pharmacies registered for the OTP Pharmacy Incentive Scheme are able to access an incentive payment of $200 + GST for completing the OTP Pharmacy Self Audit during the 6 month reporting period.

Date of OTP Pharmacy Self Audit Completion in this 6 month reporting period:

I declare that this pharmacy has completed the OTP Pharmacy Self Audit at least once during the period 1 November 2025 to 30 April 2026 *

YesNo

VALIDATION OF OTP SELF AUDITS

Pharmacies will be selected at random to provide evidence of de-identified, completed OTP Pharmacy Self Audit Forms.

By submitting this form I declare that all information in this form is true and accurate and that providing false or misleading information may result in referral to NSW Ministry of Health and/or relevant pharmacy regulatory bodies.

Pharmacist's Name *

Signature *

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