Instructions: Only use this form for Electronic Funds Transfer (EFT) claims,
cheque claims or when authorising someone else to collect cash on your behalf.
You must attach original itemised accounts and receipts to this form.
Do you want this recorded as your permanent postal address?
Mail to GPO Box 9822 in your capital city, or place in the ‘drop box’ at your
Daytime phone number
nearest Medicare office.
— The patient is the person who received the medical service
Patient’s Medicare card number
EFT payment of benefits to claimant (fully paid accounts only)
Services provided by
Do you want an EFT payment?
eg Dr A P Jones
Payment will be made by cheque
If you have already authorised Medicare to store your banking details, do you agree to
Medicare using those details to pay your benefit?
Please complete the EFT account details below
— The claimant is the person who paid for, or is likely to pay for, the
medical expenses. Benefits will be paid to this person.
Note: EFT cannot be paid into credit card or loan/mortgage accounts.
Is the claimant’s Medicare card number the same as the patient’s?
Name of bank, building
society or credit union
Branch where account is held
Claimant’s Medicare card number
Branch number (BSB)
Account number (this may not
be your card number)
Claimant’s full name
Account held in the name(s) of
Do you want these EFT account details stored for future payments?
First given name
Would you like a statement of benefit posted to you for this claim?
Date of birth
We will automatically issue a statement of benefit to you if
your claim includes in-hospital services.
Is your family registered for the Medicare Safety Net?
Business name — for non-compensation claims if the claimant is
an organisation/business that has incurred the expenses on behalf
of the patient e.g. a nursing home
Please visit or contact
Medicare on 132 011
for advice on how to register
PC1 – 04/07
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