Medicare Claim Form - Australian Government - Department Of Human Services

Download a blank fillable Medicare Claim Form - Australian Government - Department Of Human Services in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Medicare Claim Form - Australian Government - Department Of Human Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Reset form
Print form
Medicare Claim
Instructions: Only use this form when claiming by mail, Service Centre drop box, for
8
Email (optional)
unpaid accounts or when authorising an agent to receive benefits on your behalf (agents
must be present at one of our Service Centres).
@
Staple the original itemised accounts and receipts to this form.
9
Daytime phone number
Send the completed form to the Department of Human Services, GPO Box 9822 in your
capital city or place in the 'drop box' at one of our Service Centres.
Service details
– The medical services you are claiming benefit for.
Patient's details
Ref
Patient's first
Services provided by
Account paid
–The patient is the person(s) who received the medical and/or
10
no.
given name
(e.g. Dr A P Jones)
in full?
dental service.
Yes
No
1
Patient's Medicare card number
Yes
No
Claimant's details
–The claimant is the person who paid for, or is likely to pay for, the
Yes
No
medical and/or dental expenses. Medicare benefits will be paid to this person.
2
11
Is the claimant also the patient?
Was the patient an in-patient of a hospital or approved day facility?
/
/
/
/
Go to 7
Yes
What is your reference number on the above Medicare card?
Yes
Date of: Admission
Discharge
No
Claimant's Medicare card number
No
Payment of benefits
–It is important the claimant provides their bank account details.
Ref no.
12
Have you previously supplied your bank account details?
Yes
Go to 14
No
3
Dr
Mr
Mrs
Miss
Ms
Other
13
To supply or update your bank account details, please provide the following information.
These details will be used for future payments.
Family name
Medicare benefits cannot be paid via electronic funds transfer (EFT) if the nominated
account has restrictions on EFT deposits, is a credit card, or an overseas account.
First given name
Name of bank, building society
/
/
4
or credit union
Your date of birth
5
Your sex
Male
Female
Branch where the account is held
6
Business name—for non-compensation claims where the claimant is an organisation or
Branch number (BSB)
business (e.g. a nursing home) that has incurred the expenses on behalf of the patient.
Account number (this may not
be the card number)
7
Postal address —Do you want to use the address you have recorded with us?
Account held in the name(s) of
Yes
Go to 8
14
If you want a statement of benefit posted, please tick this box:
No/unsure
please
If your claim includes in-hospital services, we will automatically issue a statement of
provide address
benefit to you.
Postcode
Do you want this recorded as your permanent postal address
for everyone on your Medicare card?
Yes
No
PC1.1210
Page 1 of 2

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2