Chronic myeloid leukaemia second and third line initial PBS authority application form (PB122)
Use this form for a patient starting second or third line initial PBS subsidised treatment with a tyrosine kinase inhibitor (TKI agent) for any phase of chronic myeloid leukaemia and who has failed an adequate trial of a first or second-line TKI agent treatment.
Download and complete the Chronic myeloid leukaemia second and third line initial PBS authority application form.
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: 20 February 2020
This information was printed 6 January 2021 from https://www.servicesaustralia.gov.au/organisations/health-professionals/forms/pb122. It may not include all of the relevant information on this topic. Please consider any relevant site notices at https://www.servicesaustralia.gov.au/individuals/site-notices when using this material.