Relapsed or refractory Hodgkin lymphoma (autologous stem cell transplant (ASCT) failure) Initial PBS authority application form (PB204)

Use this form to apply for initial PBS subsidised brentuximab vedotin treatment for a patient with post-ASCT relapsed or refractory Hodgkin lymphoma.

This form can be uploaded through HPOS. Read more about form upload in HPOS.
This PDF is fillable. Download this form and complete it on your device, or print it and complete it by hand.
We’re testing a new website design. Try it out and tell us what you think. Read more about changes to this site.

Page last updated: 1 April 2017

This information was printed Monday 24 July 2017 from humanservices.gov.au/health-professionals/forms/pb204 It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.