PBS/RPBS Safety Net prescription record form and application for a Safety Net card form (PB240)

Use this form to help you keep a record of how much you have spent on PBS/RPBS medicines and to apply for a PBS Safety Net card.

Download and complete either the Word or PDF version of the:

PBS is the Pharmaceutical Benefits Scheme.

RPBS is the Repatriation Pharmaceutical Benefits Scheme.

Page 1 of this form must be typed.

Each time you have a PBS/RPBS medicine supplied, hand both pages 1 and 2 of this form to the pharmacist.

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 use self service, request someone to deal with us on your behalf, or contact us. We can help you access, complete and submit them.

Page last updated: 3 March 2022