Form Ms014.1607 Medicare Claim - Australia

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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)
Page 1 of 2
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)
Page 1 of 2
Australian Organ Donor Register (optional)
Medicare Safety Net
The Medicare Safety Net provides families and individuals with financial assistance for high
out-of-pocket costs for out-of-hospital Medicare Benefits Schedule services. For information
1
Your Medicare card number
Ref no.
or to register, go to our website humanservices.gov.au/safetynet or call 132 011.
Note: Call charges may apply.
2
Your details
Family name
Claimant’s declaration
First given name
16
I hereby claim benefit(s) for the professional service(s) to which this claim relates
and I declare that:
Permanent postal address
I have paid for, or am liable to pay, the expenses for these services
Postcode
I am the executor or administrator acting on behalf of the deceased claimant’s estate
Note: This address will be used to update the Medicare
(if applicable)
record for everyone on your Medicare card.
the services were not for the purpose of life insurance, superannuation or provident
account schemes, admission to a friendly society, health screening, mass
/
/
Date of birth
Gender Male
Female
immunisation or connected with the patient’s employment
the services were not provided by or on behalf of the Australian Government, a state,
3
territory or a local governing body or an authority established by a law of the Australian
I wish to register my consent to donate the following organs and/or tissue for
Government, a state or territory
transplantation, in the event of my death. Tick ‘All’ or as many as apply
I have not claimed for dental expenses through private health insurance, and
All
Bone tissue
Eye tissue
Heart
the information I have provided in this form is complete and correct.
Heart valves
Kidneys
Liver
I understand that:
Lungs
Pancreas
Skin tissue
giving false or misleading information is a serious offence.
Date
Claimant’s
4
I wish to register my decision not to be an organ and/or tissue donor
-
signature
/
/
5
Organ donor declaration
Privacy notice – Your personal information is protected by law, including the
I declare that:
Privacy Act 1988, and is collected by the Australian Government Department of Human
I give permission for the details I have provided to be actioned on the Australian Organ
Services for the assessment and administration of payments and services. This information
is required to process your application or claim.
Donor Register.
Your information may be used by the department or given to other parties for the purposes
I have discussed this decision with my family, partner or friend.
of research, investigation or where you have agreed or it is required or authorised by law.
I am aware that I can change my donation decision details at any time.
You can get more information about the way in which the Department of Human Services
I have read and understood the Privacy notice contained in this form.
will manage your personal information, including our privacy policy, at
Date
humanservices.gov.au/privacy or by requesting a copy from the department.
Your
-
signature
/
/
For more information
For more information, go to humanservices.gov.au/organdonor or call the Australian Organ
Donor Register on 1800 777 203.
Note: Call charges may apply.
MS014.1607 (formerly PC1)
Page 2 of 2
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