Myelodysplastic syndrome - initial PBS authority application form (PB012)

Use this form for a patient starting initial PBS subsidised treatment with lenalidomide or applying for the first continuing PBS subsidised treatment.

Download and complete the Myelodysplastic syndrome - initial PBS authority application form.

The patient and prescriber acknowledgements must be completed.

PBS is the Pharmaceutical Benefits Scheme.

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

You can upload this form in HPOS.

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 contact us. We can help you access, complete and submit them.

Page last updated: 26 May 2020