Medicare Enrolment Application Form Page 5

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Person 4
Bank account details
45
Mr
Mrs
Miss
Ms
Other
54
Note: Medicare benefits cannot be paid via Electronic Funds
Family name
Transfer (EFT) if the nominated account has restrictions on EFT
deposits, is a credit card or an overseas account.
First given name
We cannot record bank account details for children under
14 years of age.
Do you have an Australian bank account?
Other given name(s)
No
Go to 57
Yes
46
Their sex
Male
Female
55
Name of bank, building society or credit union
/
/
47
Their date of birth
Branch where your account is held
48
Previous Medicare card number (if applicable)
Ref no.
Branch number (BSB)
49
Previous name (if applicable)
Account number (this may not be your card number)
50
Were they born in Australia?
Yes
Go to 52
No
Reason for entry to Australia (e.g. migrant residing in
Account held in the name(s) of
Australia)
Attach a separate sheet with details if additional bank
Entry date
Departure date
accounts need to be listed.
/
/
/
/
51
Their country of residence prior to entering Australia
52
Please read this before answering the following questions.
Questions 22 and 23 are optional and will not affect their
application. If they do answer, the information will help us to
continue to improve services to Aboriginal, Torres Strait and
Australian South Sea Islander peoples.
Australian South Sea Islanders are the descendents of Pacific
Islander labourers brought from the Western Pacific in the 19th
Century.
They can have this information removed from their Medicare
records at any time by:
• calling the Aboriginal and Torres Strait Islander Access and
Employment line on 1800 556 955.
Note: Call charges apply from mobile phones, or
• visiting your nearest Medicare Service Centre.
Is this person of Aboriginal or Torres Strait Islander origin?
If they are of both Aboriginal and Torres Strait Islander origin,
please tick both 'Yes' boxes.
No
Yes – Aboriginal
Yes – Torres Strait Islander
53
Is this person of Australian South Sea Islander origin?
No
Yes
If more than 4 names are to be included on your card,
attach a separate sheet(s) with their details including
signatures.
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3101.1306

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