Acute Lymphoblastic Leukaemia – imatinib mesylate Initial PBS authority application form (PB078)

Use this form for a patient who is starting initial PBS subsidised treatment with imatinib mesylate for the treatment of acute lymphoblastic leukaemia.

Patients are eligible to receive a lifetime maximum of 24 months of continuing treatment with imatinib mesylate through the PBS.

PBS is the Pharmaceutical Benefits Scheme.

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.

Page last updated: 12 April 2018