Form D1181 - Application For Reimbursement Of Medical Expenses Privately Incurred - Australian Department Of Veterans' Affairs

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Application for Reimbursement of
Medical Expenses Privately Incurred
NOTE: Please read the instructions on both sides before completing the form.
Important Information: DVA will not reimburse repeat visits to a provider who does not accept DVA cards.
As soon as possible please locate a provider in your area who accepts DVA cards. The provider must be
registered through either DHS Medicare or DVA to provide services to DVA clients.
Particulars of Beneficiary who incurred the expense
File number
Surname
Given names
Full postal address
Telephone number
(
)
Postcode
Particulars of Applicant, where beneficiary is deceased or unable to apply
Surname
Given names
Relationship to Veteran
Full postal address
Telephone number
(
)
Postcode
Representative’s declaration: I certify that the statements contained on this form are correct and the goods and/or treatments have
been received by the eligible person listed above. I am aware that there are penalties for making false or misleading statements.
/
/
Representative’s signature
Date
Details of Accounts and Receipts
(Original accounts and/or receipts must be attached for all items claimed)
Benefit received
Total amount of
Full name and address
Date of
Benefit received
from Medicare
paid account or
of provider, hospital
from Health Fund
service
Australia
receipt
or pharmacist
$
c
$
c
$
c
Reasons for not using your Gold or White Card
Provider does not accept DVA card for first consult
DVA card was not presented
DVA card was not granted at the time of consult
Treated overseas
Provider did not accept the DVA card
Other (please specify below):
Applicant’s Statement
(If insufficient space please use space provided on page 2)
I certify that the above statements are correct and I have received the goods and/or treatments listed; and
I am aware that there are penalties for making false or misleading statements; and
I authorise the providers who have treated me or the beneficiary nominated on this form (select one) to disclose any
information related to the treatment listed above;
as the holder of a white card I certify the treatment claimed is for an accepted disability as determined by the Department; and
I am willing for a copy of this authorisation to be accepted with the same authority as the original.
/
/
Print
Save
Clear
Applicant's signature
Date
D1181 - 08/17 - p1 of 2

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