Aboriginal And Torres Strait Islander Medicare Enrolment And Amendment Form Page 3
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4Section 7
Details of other people to be included or changed on the card
If there is not enough space to include everyone to be listed on the card, get another copy of this section or photocopy it
and attach it to this form. You can also just write the required details on a piece of paper and attach it.
New enrolment—list all other people to be on the card
Adding a new person only
Changing the name of a person on the card
Medicare Safety Net registration
• a couple legally married and not separated with or without dependant children.
• a couple in a de facto relationship with or without dependant children.
• a single person with dependant children (a dependant child is someone under 16 years of age or a full time student
under 25 years of age whom you support.
Please provide ID (as described in Section 2) for each person being enrolled, added to the card or having their details changed.
No ID—no worries! have one of the people mentioned in Section 2 to fill in the referee statement or declaration section.
Spouse
Dependent child
Other (please specify)
First name
Second name
/
/
Family name
Sex: Male
Female
Date of birth
Other names the person is or has been known by
(indicate previous name here if notifying us of a name change)
Is this person of Aboriginal or Torres Strait Islander origin?
Yes - Aboriginal
Yes - Torres Strait Islander
No
For persons of both Aboriginal and Torres Strait Islander origin, mark both 'Yes' boxes. Responding to this question is voluntary.
Medicare number
Ref no.
(if already enrolled and known for the Medicare Safety Net)
Referee statement and declaration. Only complete this section if you have no ID.
I (full name of referee)
am providing this reference
year(s)
month(s)
because the above mentioned person cannot provide ID. 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 the information on this form is correct.
/
/
Referee signature
Date
(
)
Phone number
Name of the organisation
Spouse
Dependant child
Other (please specify)
First name
Second name
/
/
Family name
Sex: Male
Female
Date of birth
Other names the person is or has been known by
(please indicate the person’s previous name here if notifying us of a name change)
Is this person of Aboriginal or Torres Strait Islander origin?
Yes—Aboriginal
Yes—Torres Strait Islander
No
For persons of both Aboriginal and Torres Strait Islander origin, mark both 'Yes' boxes. Responding to this question is voluntary.
Medicare number
Ref no.
(if already enrolled and known for the Medicare Safety Net)
Referee statement and declaration. Only have this section completed if no ID is available.
I (full name of referee)
am providing this reference
year(s)
month(s)
because the above mentioned person cannot provide ID. 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
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