Fillable Form Ms014.1705 - Medicare Claim (Page 2 of 2) in pdf

Australian Organ Donor Register (optional)

Medicare Safety Net

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

Your Medicare card number

Ref no.

or to register, go to our website humanservices.gov.au/safetynet or call 132 011.

Note: Call charges may apply.

Your details

Family name

Claimant’s declaration

First given name

I hereby claim benefit(s) for the professional service(s) to which this claim relates

and I declare that:

Permanent postal address

•

I have paid for, or am liable to pay, the expenses for these services

Postcode

•

I am the executor or administrator acting on behalf of the deceased claimant’s estate

Note: This address will be used to update the Medicare

(if applicable)

record for everyone on your Medicare card.

•

the services were not for the purpose of life insurance, superannuation or provident

account schemes, admission to a friendly society, health screening, mass

Date of birth

Gender Male

Female

immunisation or connected with the patient’s employment

•

the services were not provided by or on behalf of the Australian Government, a state,

territory or a local governing body or an authority established by a law of the Australian

I wish to register my consent to donate the following organs and/or tissue for

Government, a state or territory

transplantation, in the event of my death. Tick ‘All’ or as many as apply

•

I have not claimed for dental expenses through private health insurance, and

All

Bone tissue

Eye tissue

Heart

•

the information I have provided in this form is complete and correct.

Heart valves

Kidneys

Liver

I understand that:

Lungs

Pancreas

Skin tissue

•

giving false or misleading information is a serious offence.

Date

Claimant’s

I wish to register my decision not to be an organ and/or tissue donor

signature

Organ donor declaration

Privacy notice – Your personal information is protected by law (including the

I declare that:

Privacy Act 1988) and is collected by the Australian Government Department of Human

•

I give permission for the details I have provided to be actioned on the Australian Organ

Services for the assessment and administration of payments and services. This information

is required to process your application or claim.

Donor Register.

•

I have discussed this decision with my family, partner or friend.

Your information may be used by the department, or given to other parties where you have

•

I am aware that I can change my donation decision details at any time.

agreed to that, or where it is required or authorised by law (including for the purpose of

research or conducting investigations).

•

I have read and understood the Privacy notice contained in this form.

Date

You can get more information about the way in which the department will manage your

Your

personal information, including our privacy policy, at

humanservices.gov.au/privacy

signature

www.

For more information

Go to humanservices.gov.au/organdonor or call the Australian Organ Donor Register on

1800 777 203.

Note: Call charges may apply.

MS014.1705 (formerly PC1)

Page 2 of 2

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Form Ms014.1705 - Medicare Claim Page 2

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