Form Ms001.1612 - Medicare Two-Way Claim
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1
2Medicare Two-way claim
Purpose of this form
Private health insurance member's details
Medicare Two-way is an Australian Government Department of Human Services initiative designed to make
1
Name of private health insurer
lodging private health insurer claims easier for people with private health insurance. Under Medicare Two-way,
you can lodge all your in-hospital and ancillary claims either with your participating private health insurer or
2
Private health insurance
membership number
with Medicare.
There are over 35 private health insurers participating in Medicare Two-way. Contact your private health
3
Family name
insurer to see if they participate in Medicare Two-way or ask at one of our service centres. If you have
questions about private health insurance claims, contact your private health insurer.
4
First given name
Filling in and returning your form
5
Postal address
•
At a service centre
Postcode
Complete this form and a Medicare claim form (MS014). If you do not have this form, go to
humanservices.gov.au/forms or visit one of our service centres.
6
Do you want this recorded as your permanent postal address?
No
www.
Check that all required questions are answered and that the form is signed and dated.
Yes
Attach your original accounts with receipts if the accounts have been paid.
(
)
Place in the drop box at one of our service centres.
7
Phone number
We will process your Medicare claim and forward your private health insurance claim to your private
health insurer for processing. Private health insurer payments will be paid by Electronic Funds Transfer
Claiming the private health insurer medical gap benefit
(EFT). To receive payment by EFT, register your bank account details with your private health insurer.
The private health insurer medical gap benefit is the difference between the Medicare benefit and the
•
At a private health insurer
Medicare schedule fee that your private health insurer will pay for in-hospital services.
Complete your private health insurance claim form as well as a Medicare claim form (MS014). If you do
humanservices.gov.au/forms or visit one of our service centres.
not have this form, go to
www.
8
Go to 13
Do you want to claim the private health insurer medical gap benefit?
No
Check that all required questions are answered and that the form is signed and dated.
Yes
Attach your original accounts with receipts if the accounts have been paid and return your completed
forms and attachment to your private health insurer. Your private health insurer will forward your Medicare
claim to the Department of Human Services for processing. Your claim will then be processed by us and
9
Hospital name
your private health insurer.
10
Is this a public hospital?
No
Go to 12
•
By mail
Yes
Complete this form and a Medicare claim form (MS014). If you do not have this form, go to
humanservices.gov.au/forms or visit one of our service centres.
www.
11
Did you elect to be treated as a private patient?
No
Send your completed form with attachments to:
Department of Human Services
Yes
GPO Box 9822
in your capital city
/
/
/
/
12
Date of hospitalisation
From
to
For more information
humanservices.gov.au/medicare or call 132 011. Note: Call charges may apply.
Go to
www.
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MS001.1612 (formerly 0543)
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