Atypical Haemolytic Uraemic Syndrome (aHUS) eculizumab Extended initial PBS authority application form (PB175)

Use this form for a patient applying for Pharmaceutical Benefits Scheme (PBS) subsidised treatment with eculizumab for extended initial treatment.

This PDF is fillable. Download this form and complete it on your device, or print it and complete it by hand.

Page last updated: 20 October 2016

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