D1221 Health Practitioner Service Voucher - Department Of Veterans' Affairs
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1
2Health Practitioner Service Voucher
o
1 Complete the Patient Details section by entering the patient’s file
Each service voucher must be
number, first name, initial and surname. If the file number is not
used only for services rendered
known, include date of birth and address.
by one practitioner to one
2 Complete all relevant sections.
patient
3 The ‘Condition Treated’ section must be completed if the veteran
holds a Repatriation Health Card for Specific Conditions (WHITE
CARD).
4 Please ensure the patient signs the form against each service.
5 Please submit the Departmental copy with your claim and ensure that
any relevant documents are attached.
6 Please ensure that the patient receives the Patient copy.
7 The Claimant copy may be retained as your record.
8 The information sought on this form is to enable service verification
and claim processing. This information will be disclosed to Medicare
Australia to process the payment.
Continued on next page
D1221 (02/09)
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Parent category: Legal