Atypical Haemolytic Uraemic Syndrome (aHUS) eculizumab Recommencement PBS authority application form (PB176)

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

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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