Form Ms014.1607 (Formerly Pc1) - Medicare Claim

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Medicare Claim
Purpose of this form: Only use this form when claiming by mail or service centre drop box,
9
Email (optional)
for unpaid accounts.
@
Staple the original itemised accounts and receipts to this form.
(
)
Returning your form: Send the completed form and copies of accounts and/or receipts to:
10
Daytime phone number
Department of Human Services, GPO Box 9822 in your capital city or place in the ‘drop
box’ at one of our service centres.
Service details
– The medical service(s) you are claiming benefit for.
Ref
Patient’s first
Services provided by
Account paid
Patient’s details
11
– The patient is the person who received the medical and/or
no.
given name
(e.g. Dr A P Jones)
in full?
dental service.
1
Patient’s Medicare card number
Ref no.
No
Yes
No
Yes
Claimant’s details
– The claimant is the person who paid for, or is likely to pay for, the
medical and/or dental expense(s). The Medicare benefit(s) will be paid to this person.
No
Yes
2
Is the claimant also the patient?
12
Was the patient an in-patient of a hospital or approved day facility?
Claimant’s Medicare card number
No
No
Ref no.
/
/
/
/
Yes
Date of admission
Date of discharge
Yes
Go to 7
Bank account details
– It is important the claimant provides their bank account details.
3
13
Dr
Mr
Mrs
Miss
Ms
Other
Have you previously supplied your bank account details?
No
Yes
Go to 15
14
To supply or update your bank account details, please provide the following information.
Family name
These details will be used for future payments.
All payments are made through Electronic Funds Transfer (EFT). Medicare benefits
First given name
cannot be paid via electronic funds transfer (EFT) if the nominated account has
/
/
restrictions on EFT deposits.
4
Date of birth
Name of bank, building society
5
Gender
Male
Female
or credit union
6
Business name – for non-compensation claims where the claimant is an organisation or
Branch where the account is held
business (e.g. a nursing home) that has incurred the expense(s) on behalf of the patient
OR
Branch number (BSB)
executor/administrator name
Account number (this may not
be the card number)
7
Postal address – Do you want to use the address you have recorded with us?
Account held in the name(s) of
No/unsure
Provide
address
Postcode
15
If you want a statement of benefit posted, please tick this box:
Yes
Go to 9
If your claim includes in-hospital services, we will automatically issue a statement of
8
Do you want this recorded as your permanent postal address
benefit to you.
for everyone on your Medicare card?
No
Yes
MS014.1607 (formerly PC1)
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