ASSISTED REGISTRATION: Application to
Register for a My Health Record
My Health Record
Purpose of this form
7. Please indicate which Medicare information, if any, you would
like included in your My Health Record.
This is an application for assisted registration under the My Health
Records Act 2012. Registration for a My Health Record is voluntary.
Medicare Information
YES
NO
You can also register free of charge online at
Details of all future claims made for Medicare
gov.au, by phoning 1800 723 471, by mail using a different form,
benefits when you receive a healthcare service
or in a Medicare Service Centre.
that is covered under the Medicare Benefits
Schedule (MBS)*
Important: You need to read the Essential Information before you
Details of any past claims for Medicare
fill out this application.
benefits, if available* (This option is only
Note: Giving false or misleading information is a serious offence.
available if you select ‘Yes’ for ‘all future claims’
for MBS above)
Application for yourself
Details of all future claims made for
Please provide the following information about yourself
Pharmaceutical benefits when you receive
medication that is covered under the
1. Family name
Pharmaceutical Benefits Scheme (PBS)**
Details of any past claims for Pharmaceutical
benefits, if available**
First given name
(This option is only available if you select ‘Yes’
for ‘all future claims’ for PBS above)
2. Gender: M
F
Your organ and/or tissue donation
decision(s),which are sourced from the
3. Date of birth (day, month, year)
Australian Organ Donor Register
/
/
Details of immunisations, which are sourced
4. Please provide ONE of the following:
from the Australian Childhood Immunisation
Register
Your Medicare Number
–
–
OR
Please note:
Your DVA File Number
* includes claims successfully processed on behalf of the
–
Department of Veterans’ Affairs (DVA), in accordance with
eligibility entitlements provided by DVA.
** includes claims successfully processed on behalf of DVA
Please read this before answering question 5
under the Repatriation Pharmaceutical Benefits.
Question 5 is optional. This information will assist in the planning and provision
of appropriate and improved healthcare and services. If you do not answer, your
Important: By completing this form you are consenting to
My Health Record will show ‘not stated’.
records containing your health information being uploaded
to the My Health Record system by registered healthcare provider
5. Are you of Aboriginal or Torres Strait Islander origin?
organisations involved in your care, subject to any express advice
No
Yes, Aboriginal
Yes, Torres Strait
you give to your healthcare providers not to upload a particular
record, a specified class of records, or any records.
Yes, both Aboriginal and Torres Strait Islander
Please read this before answering question 6
Upon the success of your application, we will provide you with an Identity Verifica-
tion Code (IVC) to access your My Health Record online.
Applicant’s signature
6. How do you wish to receive your Identity Verification Code?
By email to:
✍
Date
/
/
By SMS to
Through the healthcare provider organisation
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