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Дата канвертавання21.04.2016
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Price Application Form

Agreement on the supply terms, conditions & prices of medicines supplied to the health services Executive

November 2012

Company Name: _____________________________________________________



Address: _____________________________________________________
_____________________________________________________
_____________________________________________________
Telephone No: ____________________ Facsimile No: ___________________
Contact Person: _____________________ E-mail Address: __________________
Date of Notification: ____________

Central Bank of Ireland Euro Exchange Rates on Date of Notification:

= : Danish Krone (D.Kr) ____________


= : Pound Sterling (Stg £) ____________

I hereby certify that the notified Irish Price(s) to Wholesaler, to take effect from ______________, comply with the above Agreement of November 2012.


Signed: _____________________________________

MANAGING DIRECTOR / GENERAL MANAGER
Completion and submission of this form to the HSE means acceptance by the applicant of all the terms and conditions as set out in IPHA/HSE Agreement which came into effect on the 1st November 2012.
This form along with a copy of the marketing authorisation should be sent to;
Corporate Pharmaceutical Unit,

HSE Primary Care Reimbursement Service,

Exit 5 M50,

North Road,

Finglas,

Dublin 11.




NEW PRODUCT

(Name, form & strength)

PACK SIZE

PROPOSED DATE OF INTRODUCTION

NEW IRISH PRICE TO WHOLESALER (Note 1) €













Current EU Prices to wholesaler of the above pack size in the reference states, converted where appropriate, to Euro at the exchange rate on the date of notification (Note 2)

Austria

Belgium

Denmark D.Kr.



A



B



C

Finland

France

Germany



D



E



F

Netherlands

Spain

UK Stg£



G



H



I




Average of A+B+C+D+E+F+G+H+I






J

Completion and submission of this form to the HSE means acceptance by the applicant of all the terms and conditions as set out in IPHA/HSE Agreement which came into effect on the 1st November 2012.


This form along with a copy of the marketing authorisation should be sent to:

Corporate Pharmaceutical Unit,

HSE Primary Care Reimbursement Service,

Exit 5 M50,

North Road,

Finglas,


Dublin 11.

NOTES: 1. New Irish Price to Wholesaler is the average of A to I as set out at J.


  1. Price to Wholesaler = Price to Pharmacist less wholesale margin.




  1. If product is not available, specify N.A.




  1. If pack size is not identical, use equivalent pack price and specify E.P.P.








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