Severe chronic plaque psoriasis for patients under 18 years Initial PBS authority application form (PB116)

Use this form for the treatment of a patient under 18 years of age with etanercept for severe chronic plaque psoriasis who is starting initial or recommencing PBS subsidised treatment. This form must be completed by a dermatologist.

A dermatologist must complete this form.

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