Application for an Integrated Community Pharmacy Services Agreement (ICPSA)
Guidelines for application form
We encourage anyone who wishes to apply for an Integrated Community Pharmacy Services Agreement (ICPSA) for a new community pharmacy to notify us of their intention as soon as possible.
All requests for a new ICPSA with us must be made on this application form, and be submitted to:
Portfolio Manager Planning & Funding
We will acknowledge receipt of the application by email by within five working days. We are not responsible for applications that are not received.
Applicants are strongly encouraged to complete this application process before seeking a license to operate a pharmacy from Medicines Control and before making any commitments relying on this application being approved by us.
Note that describing a requirement as being "complied with" or stating that the services required "can be provided" (or words to such effect) are not sufficient. A full response to each question is required.
Documents supporting your application can be attached to your application form. If supplementary information is provided, please ensure your clearly cross-reference the application form with supplementary material. We may not review information we consider to be 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.
- Our Strategic Health Services Plan (SHSP) SHSP 2017
- Pharmacy Action Plan 2016-2020 Pharmacy Action Plan 2016-2020
- Our Community Pharmacy Commissioning Policy (attached)
- Integrated Community Pharmacy Services Agreement as updated/amended from time to time.
- Medicines Act 1981 and Medicines Regulations 1984.
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 we will use to determine whether to commence contract negotiations. If we choose to commence negotiations, we will not be bound in any way until the execution of a written agreement.
We will not be bound by any statement, written or verbal, made by any person other than our authorised representative in relation to this application.
We accept no responsibility for any error in this application form or related documents.