Severe active granulomatosis with polyangiitis or severe active microscopic polyangiitis - initial PBS authority application form (PB174)

Use this form for induction of remission for a patient starting initial PBS subsidised treatment with rituximab for severe active granulomatosis with polyangiitisor severe active microscopic polyangiitis.

You can also use this form for reinduction of remission for a patient who has previously received and responded to PBS subsidised treatment with rituximab for these conditions.

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

If you have a disability or impairment and use assistive technology, there are other ways you can do your business with us. You can use self service or request someone to deal with us on your behalf. If you can’t access our forms, please contact us. We can help you access, complete and submit them.

Page last updated: 10 April 2019

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