Fraudulent Medication Reporting – Community Pharmacist | Counter Fraud and Probity Services (CFPS)

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INSTRUCTIONS

Please use the form below if you work in a Community Pharmacy and wish to report an occurrence of prescription fraud. To assist with our enquiries please provide as information as possible.

SUPPORTING DOCUMENTATION

Guidance on the reporting, recording and investigation of prescription fraud for Community Pharmacists

1

2 Section A - Contractor Details

3 Section B - Patient Details

4 Section C - Details of Incident

5 Section D - Dispensing Details

6 Submit

Contact Number
Please provide a direct contact number for the person reporting this incident.
Reporter's Name
Position
Date CFPS Contacted*

DD
MM
YYYY
Time CFPS Contacted*

: HH

MM

Section A - Contractor Details:
Contractor Name
Contractor Address
Town
Postcode
Practice Number
Telephone No
Email Address

Section B - Patient Details:
Patient Forename
Patient Surname
Any alias (if known)
Patient DOB
OR Approx Age
Address
Town
Postcode
Patient HCN/CHI
Phone Number
Mobile
Description of patient:
Height
Build/Weight
Distinguishing features
Hair Colour
Hair Style
Ethnic Group*
Gender*
Vehicle details

Section C - Details of Incident:
Nature of Incident*
Date of incident
Further details
Have PSNI been informed?*
- Yes
- No
Crime Reference Number
Is CCTV footage available?
- Yes
- No
If Yes, please save a copy to disc *

* Please note the BSO are not liable for any costs incurred in retrieving CCTV footage

Section D - Dispensing Details:
Was medication prescribed/dispensed?
- Yes
- No
- N/A
If yes, please detail each drug name, quantity and strength
Do you have access to the original or a copy of the prescription?
- Yes
- No
- N/A
Was any medication requested that was not prescribed/dispensed?
- Yes
- No
If yes, please detail each drug name, quantity and strength

Any further comments:
Name
This field is for validation purposes and should be left unchanged.

CONTACT US

Counter Fraud Services
Business Services Organisation
2 Franklin Street
BELFAST
BT2 8DQ

T : 028 9536 3839
E : cfs@hscni.net

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