Polyangiitis – induction or re-induction of remission PBS authority application form (PB174)
Use this form to apply for induction or re-induction of remission PBS subsidised rituximab treatment for severe active granulomatosis with polyangiitis or severe active microscopic polyangiitis.
Download and complete the Polyangiitis induction or remission initial PBS authority application form.
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: 8 September 2020
This information was printed 15 January 2021 from https://www.servicesaustralia.gov.au/organisations/health-professionals/forms/pb174. 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.