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1. Date and Location: Current date and place where the letter is being written
2. Pharmacy Information: Name and address of the pharmacy where the medicine will be collected
3. Patient Details: Full name, address, date of birth, and Medicare number of the person authorizing collection
4. Authorized Person Details: Full name, address, and identification details of the person being authorized to collect the medicine
5. Medicine Details: Specific details of the medication(s) to be collected, including prescription numbers if applicable
6. Authorization Statement: Clear statement of authorization, specifying the exact permissions being granted
7. Validity Period: Specific timeframe for which the authorization is valid
8. Signature Block: Space for patient's signature, date, and witness signature if required
1. Special Instructions: Any specific instructions for handling or storing the medication, used when special care is required
2. Emergency Contact: Additional contact information in case of questions or issues, recommended for long-term arrangements
3. Previous Authorization Revocation: Statement revoking any previous authorizations, used when replacing an existing authorization
4. Restricted Medicine Declaration: Additional declarations required for controlled substances or restricted medications
1. Copy of Patient ID: Attached photocopy of patient's identification document
2. Copy of Authorized Person ID: Attached photocopy of authorized person's identification document
3. Prescription Details: List of relevant prescriptions and their details, if multiple medications are involved
4. Witness Declaration: Separate witness declaration form when required by pharmacy or for controlled substances
Authorized Representative
Prescription
Medication
Medicare Card
Pharmacy
Healthcare Provider
Identification Document
Authorization Period
Prescription Number
Medicare Number
Witness
Collection Date
Dispensing Pharmacy
Healthcare Identifier
Pharmaceutical Benefits Scheme
Controlled Substance
Authentication
Dispensing Record
Verification
Healthcare
Pharmaceutical
Legal Services
Medical Practice Management
Aged Care
Disability Services
Community Services
Insurance
Legal
Compliance
Healthcare Administration
Patient Services
Pharmacy Operations
Risk Management
Medical Records
Social Services
Clinical Operations
Pharmacist
Healthcare Administrator
Legal Counsel
Medical Practice Manager
Compliance Officer
Healthcare Social Worker
Patient Care Coordinator
Aged Care Coordinator
Disability Support Worker
Medical Records Officer
Healthcare Risk Manager
Pharmacy Technician
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