Application for an Integrated Community Pharmacy Services Agreement (ICPSA)

Guidelines for Application Form 1

Please find the Application Form here

Bay of Plenty District Health Board (DHB) encourages anyone who may wish to apply for an Integrated Community Pharmacy Services Agreement (ICPSA) for a new community pharmacy to notify the DHB of that intention as soon as possible.

All requests for a new ICPSA with Bay of Plenty DHB must be made on this Application Form, and be submitted to: Andrea Baker Portfolio Manager Planning & Funding andrea.baker@bopdhb.govt.nz Receipt of the application will be acknowledged by email by within five working days. Bay of Plenty DHB is not responsible for applications that are not received.

Applicants are strongly encouraged to complete this application process prior to seeking a license to operate a pharmacy from Medicines Control and prior to making any commitments which may be reliant upon this application being approved by Bay of Plenty DHB.

Applicants should note that describing a requirement as being "complied with" or stating that the services required "can be provided" (or words to such effect) is not sufficient. A full response to each question is required.

Additional documentation in support of your application can be attached to your Application Form. If supplementary information is provided, ensure that clear cross-referencing between the Application Form and supplementary material is provided. Bay of Plenty DHB may not review additional information if it considers that the information provided is outside the scope of the evaluation.

This document should be read in conjunction with:

The terms and conditions specified at the end of this form.

Health and Disability Services Pharmacy Standards (New Zealand Standard NZS 8134.7: 2010) as updated/amended from time to time. Standards

This Application Form is not an offer and does not constitute a process contract. It is an invitation to submit information that Bay of Plenty DHB will use to determine whether to commence contract negotiations. If Bay of Plenty DHB chooses to commence negotiations, it will not be bound in any way until the execution of a written agreement.

Bay of Plenty DHB will not be bound by any statement, written or verbal, made by any person other than Bay of Plenty DHB authorised representative in relation to this application.

Bay of Plenty DHB accepts no responsibility for any error in this Application Form or related documents.

Please find the Application Form here

Please read our Community Pharmacy Contracting Policy

Last updated: October 8, 2019