Medicare Enrolment Application Form Page 2
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6Contact person’s details
Documents required
•
current passport and valid visa for all applicants.
1
Please read this before answering the following questions.
Further documents may be required.
As part of this application, the Australian Government
Australian citizens that have been living overseas for more
Department of Human Services needs a contact person who
we can send general information to on behalf of those persons
than 5 years and are returning to Australia to live
enrolling in Medicare.
or
The contact person can be one of the persons enrolling on this
application or a power of attorney, carer, parent arranging card
New Zealand citizens living in Australia
for a child or a government authority.
or
Permanent resident visa holders (previously enrolled in
Mr
Mrs
Miss
Ms
Other
Medicare) returning to live in Australia
Family name
Documents required
•
completed
statutory declaration
First given name
•
passports for all people listed on the application
•
any 2 residency documents from the list below.
Other given name(s)
Residency documents
2
Your sex
Male
Female
Documents from another country
•
sale of property (sale agreement)
/
/
3
•
cessation of lease agreement for rental property
Your date of birth
•
termination of employment (acceptance of resignation by
4
Your permanent address
employer)
•
transit document for household goods and or furniture
•
closure of bank accounts, and/or
•
cancellation of health, property or contents insurance.
Postcode
Documents from Australia
Your postal address (if different to above)
•
purchase of property agreement and gas or electricity accounts
in the same name
•
lease agreement for rental of property and gas or electricity
accounts in same name
Postcode
•
evidence of employment
•
evidence of children at school or university, and/or
5
Your contact details
•
private health insurance in Australia, opening of bank accounts,
Home phone number
property or contents insurance.
(
)
Family or group Medicare cards
Mobile phone number
People can choose to be on separate Medicare cards or be included
with other people at the same address.
Daytime phone number
(
)
Medicare Safety Net
The Medicare Safety Net helps people with high medical costs.
Email
It is available to individuals as well as families. Individuals are
automatically registered but families need to register for the Safety
@
Net.
For more information about the Medicare Safety Net:
6
Will you be listed on the Medicare card as part of this enrolment?
humanservices.gov.au/safetynet
•
go to our website
www.
No
Explain why you will not be listed (e.g. power of
visit your nearest Medicare Service Centre, or call 132 011.
•
attorney, carer, parent arranging card for a child or a
Note: Call charges apply – calls from mobile phones may be
government authority)
charged at a higher rate.
Bank account details
To enable us to make payments into your bank account, you will need
You will need to attach supporting documentation
to provide your bank account details at question 54. These details
(e.g power of attorney) with this application.
will be used for future electronic payments, when you claim your
Note: documents need to be originals or certified
Medicare benefit(s).
copies.
You must tell the Department of Human Services immediately if you
Go to 13
change the account that we send your electronic payments to.
Yes
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3101.1306
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