Medicare Claim Form - Green

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Medicare claim
Instructions: Only use this form for Electronic Funds Transfer (EFT) claims,
4
Postal address
cheque claims or when authorising someone else to collect cash on your behalf.
Postcode
You must attach original itemised accounts and receipts to this form.
Do you want this recorded as your permanent postal address?
Yes
No
Mail to GPO Box 9822 in your capital city, or place in the ‘drop box’ at your
(
)
5
Daytime phone number
nearest Medicare office.
6
Email (optional)
Patient’s details
— The patient is the person who received the medical service
@
1
Patient’s Medicare card number
EFT payment of benefits to claimant (fully paid accounts only)
Ref
Patient’s first
Services provided by
Account paid
No.
given name
7
Do you want an EFT payment?
eg Dr A P Jones
in full?
Yes
No
Payment will be made by cheque
Yes
No
8
If you have already authorised Medicare to store your banking details, do you agree to
Yes
No
Medicare using those details to pay your benefit?
Yes
No
Yes
Claimant’s details
No
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.
2
Is the claimant’s Medicare card number the same as the patient’s?
Name of bank, building
society or credit union
Yes
Branch where account is held
No
Claimant’s Medicare card number
Branch number (BSB)
––
Ref No.
Account number (this may not
be your card number)
Claimant’s full name
3
Account held in the name(s) of
Family name
9
Do you want these EFT account details stored for future payments?
Yes
No
First given name
10
Would you like a statement of benefit posted to you for this claim?
Yes
No
Date of birth
/
/
We will automatically issue a statement of benefit to you if
your claim includes in-hospital services.
Sex
Male
Female
11
Is your family registered for the Medicare Safety Net?
OR
Business name — for non-compensation claims if the claimant is
an organisation/business that has incurred the expenses on behalf
Yes
of the patient e.g. a nursing home
No/unsure
Please visit or contact
*
Medicare on 132 011
for advice on how to register
Continued
PC1 – 04/07
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