Medicare Enrolment Application Form Page 3

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7
Applicant(s) details
Previous Medicare card number (if applicable)
Ref no.
It is not necessary to repeat the contact person’s information if they
are also an applicant.
8
Previous name (if applicable)
Person 1
15
9
Mr
Mrs
Miss
Ms
Other
Were you born in Australia?
Family name
Yes
Go to 11
No
Reason for entry to Australia (e.g. migrant residing in
First given name
Australia)
Other given name(s
Entry date
Departure date
16
Their sex
Male
Female
/
/
/
/
/
/
10
17
Country of residence prior to entering Australia
Their date of birth
18
Previous Medicare card number (if applicable)
Ref no.
11
Please read this before answering the following questions.
19
Previous name (if applicable)
Questions 11 and 12 are optional and will not affect your
application. If you do answer, the information will help us to
continue to improve services to Aboriginal, Torres Strait and
20
Were they born in Australia?
Australian South Sea Islander peoples.
Yes
Go to 22
Australian South Sea Islanders are the descendents of Pacific
No
Reason for entry to Australia (e.g. migrant residing in
Islander labourers brought from the Western Pacific in the 19th
Australia)
Century.
You can have this information removed from your Medicare
records at any time by:
• calling the Aboriginal and Torres Strait Islander Access and
Entry date
Departure date
Employment line on 1800 556 955.
/
/
/
/
Note: Call charges apply from mobile phones, or
21
• visiting your nearest Medicare Service Centre.
Their country of residence prior to entering Australia
Are you of Aboriginal or Torres Strait Islander origin?
22
Please read this before answering the following questions.
If you are of both Aboriginal and Torres Strait Islander origin,
please tick both 'Yes' boxes.
Questions 22 and 23 are optional and will not affect their
application. If they do answer, the information will help us to
No
continue to improve services to Aboriginal, Torres Strait and
Yes – Aboriginal
Australian South Sea Islander peoples.
Yes – Torres Strait Islander
Australian South Sea Islanders are the descendents of Pacific
12
Islander labourers brought from the Western Pacific in the 19th
Are you of Australian South Sea Islander origin?
Century.
No
They can have this information removed from their Medicare
Yes
records at any time by:
13
Do you need a duplicate Medicare card?
• calling the Aboriginal and Torres Strait Islander Access and
Employment line on 1800 556 955.
A duplicate card is a copy of your Medicare card. If you have
Note: Call charges apply from mobile phones, or
more than one person on your Medicare card you may find it
• visiting your nearest Medicare Service Centre.
useful to have a duplicate card.
Is this person of Aboriginal or Torres Strait Islander origin?
No
If they are of both Aboriginal and Torres Strait Islander origin,
Yes
please tick both 'Yes' boxes.
14
Is another person enrolling as part of this application?
No
No
Go to 54
Yes – Aboriginal
Yes
Yes – Torres Strait Islander
23
Is this person of Australian South Sea Islander origin?
No
Yes
24
Does a second person need to enrol?
Go to 54
No
Yes
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3101.1306

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