Aboriginal And Torres Strait Islander Medicare Enrolment And Amendment Form (Page 2 of 4) in pdf

Aboriginal and Torres Strait Islander Medicare enrolment and amendment form

New enrolment

(Sections 1, 2, 3, 4, 6 and 7 if required)

Volunteer Indigenous details

(Sections 1, 3, and 7)

Adding someone

(Sections 1, 3, 4, 6 and 7)

Duplicate card

(Sections 1, 4 and 6)

Changing name

(Sections 1, 2, 3, 6 and 7 if required)

Replacement card

(Sections 1, 2, 5 and 6)

Changing address

(Sections 1 and 6)

Safety net

(Sections 1, 6 and 7)

Section 1

Applicant/cardholder details (please fill out every time)

Title: Mr

Mrs

Other

First name

Second name

Family name

Other names you are or have been known by

(provide cardholder’s previous name here if notifying a name change)

Provide current address here if notifying a change of address

Postal address

Residential address

Previous address

(if known or notifying of a change of address)

(

)

Daytime phone no.

Sex:

Male

Female

Date of birth

Are you of Aboriginal or Torres Strait Islander origin?

Yes–Aboriginal

Yes–Torres Strait Islander

For persons of both Aboriginal and Torres Strait Islander origin, mark both 'Yes' boxes. This question is voluntary.

Medicare number

Ref no.

(if known)

Section 2

Proof of identity (when enrolling, making a change or requesting a replacement card)

You can use one of the following forms of identification (ID) (or a certified photocopy if you are mailing the form):

• driver's licence • birth certificate or extract • current passport • Australian Armed Services papers • marriage certificate • legal document.

A certified copy means one of the following people has signed and written ‘this is a true copy of the original document’:

• community elder • medical/health service manager/nurse • school principal • any permanent Commonwealth employee with five or more

years of continuous service • council chairperson • minister of religion • welfare organisation worker.

No ID—no worries! have the following details filled out and signed by one of the people listed above.

I (full name of referee)

am providing this reference

year(s)

month(s)

because the applicant cannot provide the ID listed above. I have known the applicant personally for

OR I can confirm their identity from the following information:

Medical records

School records

Church records

Other (please specify)

I understand it is an offence under the Health Insurance Act 1973 to make false or misleading statements relating to Medicare

benefits. I declare that to the best of my knowledge and belief, all information on this form is correct.

Referee signature

Date

(

)

Phone number

Name of the organisation

Section 3

Are there details of other people to include or change on the card?

Yes

—(please provide details in Section 7)

Section 4

Duplicate card (available if there is more than one person on the card)

Do you wish to have a second copy of your card? Yes

Section 5

Replacement card

Was your card?

Lost

Stolen

Damaged/destroyed

Expired

Section 6

Declaration (Please fill out every time)

I declare that all information on this form (including any information provided in Section 7) is correct.

I understand it is an offence under the Health Insurance Act 1973 to make a false statement relating to Medicare benefits.

Cardholder's signature

Date

Privacy note: The information on this form will be used to assess your eligibility to receive Medicare benefits and to maintain a record of persons entitled to government

program payments administered by Medicare Australia, or to amend your personal details. The information provided on this form may also be used to facilitate the allocation

of an Individual Healthcare Identifier. The collection of this information is authorised by the Health Insurance Act 1973 and the Healthcare Identifiers Act 2010. This

information may be disclosed to the Department of Human Services, Department of Health and Ageing, Department of Families, Housing, Community Services and Indigenous

Affairs, Centrelink, Department of Veterans' Affairs, State and Territory health departments or as authorised or required by law. Information concerning any identification

number given to you by Medicare Australia and your eligibility for a benefit administered by Medicare Australia may be provided to a person who renders a hospital, medical

or pharmaceutical service, to a member of the staff of that person or to a person nominated to administer your affairs.