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 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