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ASSISTED REGISTRATION: Application to

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

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

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

Your Medicare Number

–

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

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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Application To Register For A My Health Record - Department Of Health Ausrtalian Goverment

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