Imatinib mesylate (Glivec) - Blast phase Initial PBS authority application form (PB143)

Use this form for a patient undergoing initial PBS subsidised treatment of imatinib mesylate (Glivec) for treatment in the blast phase of chronic myeloid leukaemia.

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