Bank Account Details Collection Form - Medicare
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1Bank account details
Collection
Purpose of this form
Branch where the account is held
Use this form to register and store your bank account details with the
Australian Government Department of Human Services.
We will use these details for all Medicare payments where you are the
Branch number (BSB)
person who paid for the service. Other people listed on your Medicare card
Account number (this may not be your card number)
(aged 14 years and over) can use this form when consenting to use your
bank account for their Medicare payments, where that person paid for the
service.
Account held in the name(s) of
For more information
For more information, go to our website
humanservices.gov.au/online or
www.
call 132 011.
Note: Call charges apply – calls from mobile phones may be charged at a
higher rate.
Consent to nominate your bank account
Filling in this form
7
Only complete this section if other people listed on your Medicare
•
Please use black or blue pen
card (aged 14 years and over) agree to use your bank account for
•
Print in BLOCK LETTERS
their Medicare payments, where they are the person who paid for
the service.
✓
7
•
Mark boxes like this
with a
or
I authorise for payments to be made into the nominated bank account.
Returning your form
Full name of person 1
Send your completed form to:
Department of Human Services
Medicare
Signature of person 1
GPO Box 9822
Date
in your capital city
-
or visit one of our service centres.
/
/
Full name of person 2
Your
details
1
Medicare card number
Signature of person 2
Date
Ref no.
-
/
/
2
Dr
Mr
Mrs
Miss
Ms
Other
Family name
If there are more than 2 other people, attach a separate
sheet with their details and signatures.
First given name
Privacy notice
8
Your personal information is protected by law, including the
3
Privacy Act 1988, and is collected by the Australian Government
Date of birth
/
/
Department of Human Services for the assessment and administration
4
Postal address
of payments and services. This information is required to process your
application or claim.
Your information may be used by the department or given to other
parties for the purposes of research, investigation or where you have
agreed or it is required or authorised by law.
Postcode
You can get more information about the way in which the Department
of Human Services will manage your personal information, including
5
(
)
Daytime phone number
humanservices.gov.au/privacy or by requesting
our privacy policy, at
www.
Email
a copy from the department.
Medicare card holder’s declaration
@
9
I declare that:
•
I will inform the Australian Government Department of Human
Bank account details
Services without delay of changes to my bank account details.
6
•
the information I have provided in this form is complete and
All Medicare benefits are paid through Electronic Funds Transfer
correct.
(EFT). Payments cannot be made via EFT if the nominated account
has restrictions on EFT deposits.
I understand that:
Do not include an account used exclusively for funding from the
•
giving false or misleading information is a serious offence.
National Disability Insurance Scheme.
Signature
Date
Name of bank, building society or credit union
-
/
/
1 of 1
MS013.1509 (formerly 1579a)
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