Medicare Enrolment Application Form Page 4
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1
2
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6Person 2
Person 3
25
35
Mr
Mrs
Miss
Ms
Other
Mr
Mrs
Miss
Ms
Other
Family name
Family name
First given name
First given name
Other given name(s)
Other given name(s)
26
36
Their sex
Male
Female
Their sex
Male
Female
/
/
/
/
27
37
Their date of birth
Their date of birth
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38
Previous Medicare card number (if applicable)
Previous Medicare card number (if applicable)
Ref no.
Ref no.
29
39
Previous name (if applicable)
Previous name (if applicable)
30
40
Were they born in Australia?
Were they born in Australia?
Yes
Go to 32
Yes
Go to 42
No
Reason for entry to Australia (e.g. migrant residing in
No
Reason for entry to Australia (e.g. migrant residing in
Australia)
Australia)
Entry date
Departure date
Entry date
Departure date
/
/
/
/
/
/
/
/
31
41
Their country of residence prior to entering Australia
Their country of residence prior to entering Australia
32
42
Please read this before answering the following questions.
Please read this before answering the following questions.
Questions 22 and 23 are optional and will not affect their
Questions 22 and 23 are optional and will not affect their
application. If they do answer, the information will help us to
application. If they do answer, the information will help us to
continue to improve services to Aboriginal, Torres Strait and
continue to improve services to Aboriginal, Torres Strait and
Australian South Sea Islander peoples.
Australian South Sea Islander peoples.
Australian South Sea Islanders are the descendents of Pacific
Australian South Sea Islanders are the descendents of Pacific
Islander labourers brought from the Western Pacific in the 19th
Islander labourers brought from the Western Pacific in the 19th
Century.
Century.
They can have this information removed from their Medicare
They can have this information removed from their Medicare
records at any time by:
records at any time by:
• calling the Aboriginal and Torres Strait Islander Access and
• calling the Aboriginal and Torres Strait Islander Access and
Employment line on 1800 556 955.
Employment line on 1800 556 955.
Note: Call charges apply from mobile phones, or
Note: Call charges apply from mobile phones, or
• visiting your nearest Medicare Service Centre.
• visiting your nearest Medicare Service Centre.
Is this person of Aboriginal or Torres Strait Islander origin?
Is this person of Aboriginal or Torres Strait Islander origin?
If they are of both Aboriginal and Torres Strait Islander origin,
If they are of both Aboriginal and Torres Strait Islander origin,
please tick both 'Yes' boxes.
please tick both 'Yes' boxes.
No
No
Yes – Aboriginal
Yes – Aboriginal
Yes – Torres Strait Islander
Yes – Torres Strait Islander
33
43
Is this person of Australian South Sea Islander origin?
Is this person of Australian South Sea Islander origin?
No
No
Yes
Yes
34
44
Does a third person need to enrol?
Does a fourth person need to enrol?
Go to 54
Go to 54
No
No
Yes
Yes
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3101.1306
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