PBS/RPBS Safety Net prescription record form and application for a Safety Net card form (PB240)

Use this form to help you keep a record of how much you have spent on PBS/RPBS medicines and to apply for a PBS Safety Net card.

You must download our forms and fill them in so they are processed quickly. You can also electronically sign some of our forms. We have help available if you use assistive technology.

Download and complete either the Word or PDF version of the:

PBS is the Pharmaceutical Benefits Scheme.

RPBS is the Repatriation Pharmaceutical Benefits Scheme.

Page 1 of this form must be typed.

Each time you have a PBS/RPBS medicine supplied, hand both pages 1 and 2 of this form to the pharmacist.

Page last updated: 17 November 2022.
QC 46946