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.

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.

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

If you have a disability or impairment and use assistive technology, there are other ways you can do your business with us. You can use self service or request someone to deal with us on your behalf. If you can’t access our forms, please contact us. We can help you access, complete and submit them.

Page last updated: 18 January 2019