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.

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Page last updated: 20 February 2020