Idiopathic thrombocytopenic purpura Initial PBS authority application form (PB097)

Use this form for an adult patient starting initial PBS subsidised treatment with either eltrombopag or romiplostim for the treatment of severe chronic immune idiopathic thrombocytopenic purpura.

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: 27 August 2017