Fast-Track Enrollment For The Oregon Health Plan Page 2
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3Gastrointestinal stromal tumour – adjuvant
Initial PBS authority application
Patient’s details
Prescriber’s details
1
6
Medicare card number
Prescriber number
Ref no.
2
Department of Veterans’ Affairs card number
7
Dr
Mr
Mrs
Miss
Ms
Other
Family name
3
Mr
Mrs
Miss
Ms
Other
First given name
Family name
8
First given name
Daytime phone number
(
)
Other given name(s)
Mobile phone number
Fax number
4
Date of birth
(
)
/
/
Prescriber’s acknowledgement
Patient’s acknowledgement
9
I have explained the circumstances governing PBS subsidised
5
I acknowledge that Pharmaceutical Benefits Scheme (PBS)
treatment with imatinib mesylate for the treatment of resected
subsidised treatment with imatinib mesylate for the treatment
primary gastrointestinal stromal tumour, with a high risk of
of resected primary gastrointestinal stromal tumour, with a high
recurrence.
risk of recurrence, will stop when I have received 36 months of
treatment.
I believe these to be understood and accepted by the patient.
Prescriber’s signature
Patient’s signature
-
-
Date
Date
/
/
/
/
Witness’s acknowledgement
10
I have witnessed the signatures of BOTH the patient and the
prescriber.
Witness’s full name (over 18 years of age)
Witness’s signature
-
Date
/
/
2 of 3
PB057.1312 (formerly 8011)
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