Form Ms001.1612 - Medicare Two-Way Claim Page 2
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2Ancillary claim details
Privacy notice
15
Your personal information is protected by law (including the Privacy Act 1988 ) and is collected by the
Ancillary services are services such as dental, optical and physiotherapy. Ancillary claims do not attract a
Australian Government Department of Human Services for administrating payments and services. This
Medicare benefit. However, as part of the Medicare Two-way service, you are able to complete a Medicare
information is required to assist with your application or claim.
Two-way claim form (MS001). Attach all original accounts with receipts if paid and lodge your ancillary
claim at one of our service centres. Your claim will be forwarded to your private health insurer for processing.
Your information may be used by the Department, or given to other parties: where you have agreed to
that; or where it is required or authorised by law (including for the purpose of research or conducting
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Are you making a claim for any ancillary services?
No
Go to 15
investigations).
Yes
You can get more information about the way in which the Department will manage your personal
information, including our privacy policy, at
humanservices.gov.au/privacy
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Ancillary claim details
www.
Member's first given name
Services provided by
Account paid?
Declaration
No
Yes
16
I hereby claim benefits for the professional services to which this claim relates and
No
Yes
I declare that:
No
Yes
•
I have paid for, or am liable to pay, the expenses for these services.
No
Yes
•
there is no entitlement to claim compensation or damages from any other source.
No
Yes
•
the services were not for the purpose of health screening, superannuation entry or a health
examination requested by an employer.
No
Yes
•
the information I have provided in this form is complete and correct.
No
Yes
I understand that:
No
Yes
•
giving false or misleading information is a serious offence.
I authorise:
•
my private health insurer to contact the provider of any professional service for clarification of any
details in this claim.
•
the Australian Government Department of Human Services to forward my Medicare statement
of benefit for in-hospital services associated with the attached Medicare claim form (MS014)
electronically or manually to my private health insurer.
Date
Private health insurance
-
/
/
member's signature
Reset form
Print form
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MS001.1612 (formerly 0543)
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