PBS Safety Net claim for payment form (PB241)

Use this form if you are an approved supplier claiming a payment for issuing a PBS Safety Net card.

PBS is the Pharmaceutical Benefits Scheme.

We require you to keep a copy of the completed form that is submitted to the department for your records.

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: 18 January 2019

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