PBS/RPBS Safety Net prescription record form and application for a Safety Net card form (PB240)

Use this form to help you keep a record of how much you have spent on PBS/RPBS medicines and to apply for a PBS Safety Net card.

Download and complete either the Word or PDF version of the:

PBS is the Pharmaceutical Benefits Scheme.

RPBS is the Repatriation Pharmaceutical Benefits Scheme.

Page 1 of this form must be typed.

Each time you have a PBS/RPBS medicine supplied, hand both pages 1 and 2 of this form to the pharmacist.

This PDF is fillable. You can fill it out on your device, or print it and complete it by hand.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please use self service, request someone to deal with us on your behalf, or contact us. We can help you access, complete and submit them.

Page last updated: 31 August 2020