Acute myeloid leukaemia - oral azacitidine - dose escalation therapy continuing authority application form (PB355)

Use this form to apply for dose escalation therapy to continue PBS-subsidised treatment with azacitidine for acute myeloid leukaemia.

Please note: You don’t need to complete this form if you use the Online PBS Authorities system.

Download and complete the acute myeloid leukaemia - azacitidine - dose escalation therapy continuing authority application form.

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.

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: 1 December 2023.
QC 65207