Chronic myeloid leukaemia second and third line initial PBS authority application form (PB122)

Use this form for a patient starting second or third line initial PBS subsidised treatment with a tyrosine kinase inhibitor (TKI agent) for any phase of chronic myeloid leukaemia and who has failed an adequate trial of a first or second-line TKI agent treatment.

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

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Page last updated: 13 February 2019

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