Medicare Claim Form - Green (Page 2 of 2) in pdf

Claimant’s declaration

Organ Donor Registration

I hereby claim benefits for the professional services to which this claim relates and

(optional)

I declare that:

•

I have paid for, or am liable to pay, the expenses for these services

Your reference

Your Medicare card number

•

the services were not for the purpose of life insurance, superannuation or

number

provident account schemes, admission to a friendly society, health screening,

mass immunisation, or connected with the patient’s employment

Your details

Family name

•

the services were not provided by or on behalf of the Commonwealth, a state

First given

or territory or a local governing body or an authority established by a law of the

name

Commonwealth, a state or territory

•

to the best of my knowledge and belief all of the information in this claim is

Date of birth

Sex

Male

Female

true and correct.

I understand that:

I wish to register my consent to donate the following organs and/or tissues

•

it is an offence under the Health Insurance Act 1973 to make a false statement

for transplantation, in the event of my death. Tick ‘All’ or as many as apply

relating to Medicare benefits.

All

Bone tissue

Eye tissue

Heart

Date

Claimant’s

Heart valves

Kidneys

Liver

signature

Lungs

Pancreas

Skin tissue

I wish to register my decision not to be an organ and/or tissue donor

Do you want to authorise another person (i.e. an agent) to collect cash on your behalf?

Note: We will ask your agent to provide satisfactory personal identification before

Would other members of your family like to register?

collecting cash on your behalf.

If you would like another form allowing up to four people who live at the same address to

Yes

Please give details

Agent’s full name

Statement

•

I give permission for all details I have provided to be included on the Australian

Permanent

Organ Donor Register.

address

•

I have discussed this decision with my family, partner or friend.

•

I am aware that I can change these details at any time.

Postcode

Date

Your

Agent’s

signature

When we have processed your registration we will send a confirmation letter to your

Claimant’s

postal address recorded by Medicare Australia.

signature

Further

Visit Medicare Australia’s website at

information

or for more information about:

• Medicare call 132 011

Privacy note — The information provided on this form will be used to assess any Medicare benefit

• the Australian Organ Donor Register call 1800 777 203

payable for the services rendered and may be used to update enrolment records. Its collection is

authorised by provisions of the Health Insurance Act 1973. The information may be disclosed to the

Privacy note — The establishment of the Australian Organ Donor Register (the Donor Register) is

Department of Human Services, Department of Health and Ageing, Centrelink, other relevant agencies or

authorised by a service arrangement under subsection 7(2) of the Medicare Australia Act 1973. The

to a person in the medical practice associated with this claim or as authorised/required by law.

information on the Donor Register will be available to authorised personnel in the organ and tissue

Information about medical expense totals may also be disclosed to other family members for taxation

donation network who have signed confidentiality agreements covering your personal information.

statement purposes and the monitoring of family safety net entitlements. Patient names and addresses

may be disclosed to financial institutions when the claim is paid.

Call charges apply

Call charges apply from mobile or pay phones only

PC1 – 04/07

Page 2 of 2

Medicare Claim Form - Green Page 2

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