Retinal Vein Occlusion Initial Pbs Authority Application Page 2
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1
2
3Retinal Vein Occlusion
Initial PBS authority application
Patient’s details
Conditions and criteria
1
9
Medicare card number
To establish eligibility for PBS authority approval under this
criterion, the following information must be supplied for the
Ref no.
relevant eye(s).
or
The patient:
Department of Veterans’ Affairs card number
has visual impairment due to macular oedema secondary to:
Branched Retinal Vein Occlusion (BRVO)
2
Mr
Mrs
Miss
Ms
Other
Right eye
Left eye
Family name
and
has a Best-Corrected Visual Acuity (BCVA) score
based on the Early Treatment Diabetic Retinopathy
First given name
Study (ETDRS) chart of between 73 and 20 letters
administered at a distance of 4 metres
(approximate Snellen equivalent 20/40 to 20/400)
3
Date of birth
in the eye(s) proposed for treatment
/
/
Right eye
Left eye
4
Sex
and
Male
this applies for treatment with
Female
ranibizumab as the sole PBS subsidised therapy
for this condition
Appointment details
or
Central Retinal Vein Occlusion (CRVO)
5
Scheduled appointment
Right eye
Left eye
Date
and
/
/
has a Best-Corrected Visual Acuity (BCVA) score
Time
Select 'am' or 'pm'
based on the Early Treatment Diabetic Retinopathy
.
am/pm
am/pm
Study (ETDRS) chart of between 73 and 24 letters
administered at a distance of 4 metres
(approximate Snellen equivalent 20/40 to 20/320)
Prescriber’s details
in the eye(s) proposed for treatment
6
Prescriber number
Right eye
Left eye
and
this applies for treatment with
7
Dr
Mr
Mrs
Miss
Ms
Other
aflibercept as sole PBS subsidised therapy for this
condition
Family name
or
ranibizumab as sole PBS subsidised therapy for
First given name
this condition
8
Business phone number
(
)
Alternative phone number
Fax number
(
)
2 of 3
PB154.1510
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