Retinal Vein Occlusion Initial Pbs Authority Application (Page 3 of 3) in pdf

Retinal Vein Occlusion Initial Pbs Authority Application Page 3

and

has been diagnosed by fluorescein angiography

Right eye

Left eye

Date of report

Give details on contraindication to fluorescein angiogram

Attach a copy of the report of an alternative

method of diagnosis.

Attachments

Attach a copy of the diagnostic report and completed

authority prescription form.

Privacy notice

Your personal information is protected by law, including the

Privacy Act 1988, and is collected by the Australian Government

Department of Human Services for the assessment and

administration of payments and services. This information is

required to process your application or claim.

Your information may be used by the department or given to

other parties for the purposes of research, investigation or

where you have agreed or it is required or authorised by law.

You can get more information about the way in which the

Department of Human Services will manage your personal

information, including our privacy policy, at

humanservices.gov.au/privacy or by requesting a copy from

www.

the department.

Prescriber’s declaration

I declare that:

•

the information I have provided in this form is complete and

correct.

I understand that:

•

giving false or misleading information is a serious offence.

Prescriber’s signature

Date

Reset form

Print form

3 of 3

PB154.1510

Retinal Vein Occlusion Initial Pbs Authority Application Page 3