Medicare Claim Form - Black And White
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1
2Medicare claim
Instructions: Only use this form for unpaid accounts or when not claiming in person or when
4
Postal address
authorising an agent to claim on your behalf.
Postcode
You must attach original itemised accounts and receipts to this form.
Do you want this recorded as your permanent postal address?
Yes
No
Mail to Medicare, GPO Box 9822, in your capital city, or place in the ‘drop box’ at your local
(
)
5
Daytime phone number
Medicare office.
6
Email (optional)
Patient’s details
— The patient is the person who received the medical service
@
1
Patient’s Medicare card number
7
Was the patient an in-patient of a hospital or approved day facility?
Ref
Patient’s first
Services provided by
Account paid
Yes
Date of:
Admission
/
/
Discharge
/
/
no.
given name
e.g. Dr A P Jones
in full?
No
Yes
No
Payment of benefits
— It is important you provide your bank account details.
Yes
No
8
Have you previously supplied your bank account details?
Yes
No
Yes
No
9
To supply or update your bank account details, please provide the following
Claimant’s details
— The claimant is the person who paid for, or is likely to pay for, the
information. These details will be used for future payments.
medical expenses. Benefits will be paid to this person.
Note: EFT cannot be paid into credit card or loan/mortgage accounts.
2
Is the claimant’s Medicare card number the same as the patient’s?
Name of bank, building
Yes
society or credit union
No
Claimant’s Medicare card number
Branch where account is held
Ref no.
Branch number (BSB)
––
Account number (this may not
Claimant’s full name
3
be your card number)
Family name
Account held in the name(s) of
First given name
10
If you want a statement of benefit posted, please tick this box
Date of birth
/
/
We will automatically issue a statement of benefit to you if
your claim includes in-hospital services.
Sex
Male
Female
11
Is your family registered for the Medicare Safety Net?
OR
Business name — for non-compensation claims if the claimant is
an organisation/business that has incurred the expenses on behalf
Yes
No/unsure
*
Visit or call 132 011
of the patient e.g. a nursing home
for information about how to register
Signature required overleaf
PC1 – 02/08
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