Fillable Medicare Claim Form - Black And White (Page 2 of 2) in pdf

Claimant’s declaration

Organ Donor Registration

I hereby claim benefits for the professional services to which this claim relates and

(optional)

I declare that:

•

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

Your reference

Your Medicare card number

•

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

number

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

mass immunisation, or connected with the patient’s employment

Your details

Family name

•

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

First given

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

name

Commonwealth, a state or territory

•

to the best of my knowledge and belief all of the information in this claim is

Date of birth

Sex

Male

Female

true and correct.

I understand that:

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

•

it is an offence under the Health Insurance Act 1973 to make a false statement

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

relating to Medicare benefits.

All

Bone tissue

Eye tissue

Heart

Date

Claimant’s

Heart valves

Kidneys

Liver

signature

Lungs

Pancreas

Skin tissue

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

Do you want to authorise another person (e.g. an agent) to collect benefits on your behalf?

Note: We will ask your agent to provide satisfactory personal identification before

Would other members of your family like to register?

collecting benefits on your behalf.

If you would like another form allowing up to four people who live at the same address to

Yes

Please give details of your agent

Full name

Statement

•

I give permission for all details I have provided to be included on

Permanent

the Australian Organ Donor Register.

address

•

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

•

I am aware that I can change these details at any time.

Postcode

Date

Your

Agent’s

signature

When we have processed your registration we will send a confirmation letter to your

Claimant’s

postal address recorded by Medicare Australia.

signature

Further

Visit Medicare Australia’s website at

information

or call:

• Medicare 132 011

Privacy note — The information provided on this form will be used to assess any Medicare benefit

payable for the services rendered and may be used to update enrolment records. The EFT details

• the Australian Organ Donor Register 1800 777 203

collected will be used for any future payments to you from programs administered by Medicare Australia.

Its collection is authorised by provisions of the Health Insurance Act 1973. The information may be

Privacy note — The establishment of the Australian Organ Donor Register (the Donor Register) is

disclosed to the Department of Health and Ageing, Centrelink, other relevant agencies or to a person in

authorised by a service arrangement under subsection 7(2) of the Medicare Australia Act 1973. The

the medical practice associated with this claim or as authorised or required by law. Patient names and

information on the Donor Register will be available to authorised personnel in the organ and tissue

addresses may be disclosed to financial institutions when the claim is paid. Information about medical

donation network who have signed confidentiality agreements covering your personal information.

expenses for people under the age of 18 may also be disclosed to adults on the same Medicare card,

through taxation statements.

Call charges apply

Call charges apply from mobile or pay phones only

PC1 – 02/08

Page 2 of 2

Medicare Claim Form - Black And White Page 2

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