Aboriginal Health Services (AHS) pharmaceutical supplies request form (PB042)

Use this form to request and claim payment for the provision of eligible pharmaceutical benefits to an approved AHS.

Download and complete the Aboriginal Health Services (AHS) pharmaceutical supplies request and claim form.

You can only claim for payment of the section 100 (s100) Remote Area Aboriginal Health Services (RAAHS) patient specific medicine supply fee (PSMSF) for eligible pharmaceutical benefits provided on or after 1 January 2018.

If you’re claiming the s100 RAAHS PSMSF for eligible pharmaceutical benefits provided before this date you need to send your claim to the Pharmacy Guild of Australia.

To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.

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: 3 March 2022