Application for an Integrated Community Pharmacy Services Agreement (ICPSA)

Guidelines and forms

Application Form 1

Lakes 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 Lakes DHB must be made on this Application Form and be submitted to

Receipt of the application will be acknowledged by email by within five working days.

Lakes 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 Lakes 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.

Lakes 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.
  • Te Manawa Rahi Lakes District Health Board Strategic Plan 2019-2021
  • Lakes DHB Community Pharmacy Strategic Plan 2019 to 2025
  • Pharmacy Action Plan 2016-2020
  • Lakes DHB Community Pharmacy Contracting Policy
  • 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.

This Application Form is not an offer and does not constitute a process contract. It is an invitation to submit information that Lakes DHB will use to determine whether to commence contract negotiations.

If Lakes DHB chooses to commence negotiations, it will not be bound in any way until the execution of a written agreement.

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

Lakes DHB accepts no responsibility for any error in this Application Form or related documents.

Please find Contracting Policy Document Number 37519 here.