Business phone number should be a 10 digit number.
Alternative phone number is required.
Alternative phone number should be a 10 digit number.
Hospital details
7.
Hospital name is required.
This hospital is a:
Hospital type is required.
8.
Hospital provider number is required.
Hospital provider number should be a 8 digit number.
Conditions and criteria
To qualify for PBS authority approval, the following conditions must be met.
9.
The patient, 12 years or over, is being treated by a medical practitioner who is:
Please check.
10.
The patient has been:
or
Please check.
11.
The patient has:
or
Please check.
12.
Will this treatment be used in combination with and within 4 weeks of another PBS-subsidised biological medicine for severe asthma?
Please check.
13.
Has the patient had asthma for at least 1 year?
Please check.
14.
The patient has a diagnosis of asthma, confirmed and documented in the patient’s medical records by either:
or
Please check.
15.
The patient’s diagnosis was defined at the time by at least one of the following standard clinical features:
Please check.
16.
The patient has:
Current dose from is required.
Current dose to is required.
and
Current dose from is required.
Current dose to is required.
and (for dupilumab 300 mg applications only)
Please select at least one option.
or
Please check.
17.
Provide details of contraindications and/or intolerances of a severity necessitating permanent treatment withdrawal to standard therapy according to the relevant TGA-approved Product Information. For details of the toxicity criteria, go to www.servicesaustralia.gov.au/healthprofessionals
Inhaled corticosteroid is required.
Inhaled long acting beta-2 agonist therapy is required.
Oral corticosteroids is required.
18.
The patient has failed to achieve adequate control with optimised asthma therapy in the past 12 months, despite formal assessment of and adherence to correct inhaler technique, which has been documented in the patient’s medical records and demonstrated by:
Date of exacerbation is required.
or
Date of exacerbation is required.
or
Please check.
Date of exacerbation is required.
Please check.
19.
Does the patient have a baseline Asthma Control Questionnaire (ACQ-5) score of ≥ 2.0 (no more than one month old)?
You must provide a recent ACQ5
Please check.
The relevant attachments need to be provided with this form.
Please upload the file.
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20.
Provide baseline details
ACQ-5 Score is required.
Date is required.
The relevant attachments need to be provided with this form.
Please upload the file.
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21.
This application is for:
Please check.
22.
Which qualifying blood test results will be provided with this authority application?
Please check.
23.
In the last 12 months, the patient has had:
cells per microlitre
Blood eosinophil count is required.
Date is required.
or (not applicable to dupilumab 300 mg applications)
cells per microlitre
Blood eosinophil count is required.
Date is required.
Please check.
The relevant attachments need to be provided with this form.
Please upload the file.
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24.
In the last 12 months, the patient has had:
or
Please check.
The relevant attachments need to be provided with this form.
Please upload the file.
0%
25.
Provide the patient’s total serum human IgE (no more than 12 months old)
IU/mL
IgE result is required.
Date is required.
Checklist
26.
The relevant attachments need to be provided with this form.
Please select the file.
Please click upload button.
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Privacy notice
27.
Personal information is protected by law (including the Privacy Act 1988 ) and is collected by Services Australia for the purposes of assessing and processing this authority application.
Personal information may be used by Services Australia, or given to other parties where the individual has agreed to this, or where it is required or authorised by law (including for the purpose of research or conducting investigations).
More information about the way in which Services Australia manages personal information, including our privacy policy, can be found at www.servicesaustralia.gov.au/privacypolicy
Prescriber’s declaration
You do not need to sign the declaration if you complete this form using Adobe Acrobat Reader and return this form through Health Professional Online Services (HPOS) at www.servicesaustralia.gov.au/hpos
28.
I declare that:
I am aware that this patient must meet the criteria listed in the current Schedule of Pharmaceutical Benefits to be eligible for this medicine.
I have informed the patient that their personal information (including health information) will be disclosed to Services Australia for the purposes of assessing and processing this authority application.
I have provided details of the proposed prescription(s) and the relevant attachments as specified in the Pharmaceutical Benefits Scheme restriction.
the information I have provided in this form is complete and correct.
I understand that:
giving false or misleading information is a serious offence.