Medicare Claim Form - Australian Government - Department Of Human Services Page 2
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1
2Australian Organ Donor Register (optional)
15
Do you want to authorise another person (e.g. an agent) to collect benefits on your behalf?
We will ask your agent to provide satisfactory personal identification before receiving
benefits on your behalf. Your Medicare benefit will be paid via Credit EFTPOS into your
agent's bank account. Your agent will be required to hold a debit card in order to complete
1
Your Medicare card number
Ref no.
the transaction.
2
Your details
Family name
Please give details of your agent
Yes
Full name
First given name
Permanent address
Permanent
address
Postcode
Postcode
Note: This address will be used to update the Medicare
Agent's
record for everyone on your Medicare card.
signature
-
/
/
Date of birth
Sex Male
Female
No
3
I wish to register my consent to donate the following organs and/or tissue for
Medicare Safety Net
transplantation, in the event of my death. Tick 'All' or as many as apply
The Medicare Safety Net provides families and individuals with financial assistance for high
out-of-pocket costs for out-of-hospital Medicare Benefits Schedule services. For information
All
Bone tissue
Eye tissue
Heart
or to register, go to our website at humanservices.gov.au/safetynet or call 132 011.
Heart valves
Kidneys
Liver
Note: Call charges apply. Calls from mobile phones may be charged at a higher rate.
Lungs
Pancreas
Skin tissue
Claimant's declaration
16
I hereby claim benefits for the professional service(s) to which this claim relates and
4
I wish to register my decision not to be an organ and/or tissue donor
I understand that:
•
It is an offence under the Health Insurance Act 1973 and the Dental Benefits Act 2008
5
Declaration
to make a false statement relating to Medicare benefits.
•
I give permission for the details I have provided to be actioned on the Australian Organ
I declare that:
Donor Register.
•
I have paid for, or am liable to pay, the expenses for these services
•
the services were not for the purpose of life insurance, superannuation or provident
•
I have discussed this decision with my family, partner or friend.
account schemes, admission to a friendly society, health screening, mass
•
I am aware that I can change these details at any time.
immunisation or connected with the patient's employment
•
the services were not provided by or on behalf of the Australian Government, a state,
Date
Your
territory or a local governing body or an authority established by a law of the Australian
-
signature
/
/
Government, state or territory
•
I have not claimed for dental expenses through private health insurance, and
•
the information in this form is complete and correct.
For more information
Date
Claimant's
Go to humanservices.gov.au/organdonor or call the Australian Organ Donor Register on
-
signature
1800 777 203. Note: Call charges apply from mobile phones.
/
/
Privacy and your personal information – The information on this form will be used to assess a
Privacy notice – Your personal information is protected by law, including the Privacy Act 1988, and is
Medicare and/or dental benefit payable for the services rendered and may be used to update enrolment
collected for a Social Security, Family Assistance, Medicare, Child Support and CRS purpose, depending
records. The EFT details collected will be stored and used for any future payments to you from programs
on the service or payment concerned. This information may be required by law or collected voluntarily
administered by The Department of Human Services. The collection of this information is authorised
when you apply for services or payments. Your information is used for the assessment and administration
by the Health Insurance Act 1973 and the Dental Benefits Act 2008. This information may be disclosed to
of payments and services and may also be used within Human Services; or disclosed to other parties
the Department of Health and Ageing, other relevant agencies or to a person in the medical and/or dental
or agencies, where you have provided consent or it is required or authorised by law. You can get more
information about privacy by going to our website at humanservices.gov.au/privacy or requesting a
practice associated with this claim or as authorised or required by law. Patient names and addresses
copy of the full privacy policy at any of our Service Centres.
may be disclosed to financial institutions when the claim is paid. Information about medical and/or dental
expenses for people under the age of 18 may also be disclosed to adults on the same Medicare card,
through taxation statements.
PC1.1210
Page 2 of 2
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