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.

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