Medicare Enrolment Form (MS004) - Fill, Sign Online, Download & Print - No Signup
MS004.2403
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Some people can enrol online using their myGov account.
For more information go to
www.
servicesaustralia.gov.au/enrolmedicare
When to use this form
Use this form to enrol in Medicare for the first time, re-enrol in
Medicare or enrol your newborn child in Medicare.
This form allows you to enrol up to 5 people in Medicare. If you have
more than 5 people to enrol, you will need to complete an additional
Medicare enrolment form.
Family and domestic violence
If you are affected by family and domestic violence, there is help
available. Call
132 850
Monday to Friday, 8am to 5pm local time,
and ask to speak to a social worker. Otherwise, you can contact
1800RESPECT
1800 737 732
, a 24 hour service. If you are in
immediate danger, call
000
.
For more information, go to
www.
servicesaustralia.gov.au/domesticviolence
Medicare Safety Nets
If you need to see a doctor or get tests regularly, you could end up
with high medical costs. Medicare Safety Nets can help to lower your
costs for out of hospital services. We will register you as an
Individual if you are enrolled in Medicare. If you are part of a family
or couple, you can choose to register as a family to combine your
costs.
For more information go to
www.
servicesaustralia.gov.au/safetynet
Bank account details
We pay Medicare benefits to you using Electronic Funds Transfer
(EFT). To pay you, we need current bank details.
If we do not have bank details we will hold your Medicare benefit
until you provide bank details to us.
For more information go to
www.
servicesaustralia.gov.au/getmedicarebenefits
Lifetime Health Cover
Lifetime Health Cover (LHC) is a financial loading that can be payable
in addition to the base rate premium for private health insurance
hospital cover. It is designed to encourage people to take and
maintain private health insurance hospital cover earlier in life.
To avoid paying a LHC loading, hospital cover needs to be purchased:
•
by 1 July following a person’s 31st birthday, or
•
within 12 months of being registered with Medicare.
Eligible newly arrived Australian residents aged 31 years or older will
not have to pay a LHC loading if private hospital cover is purchased
within 12 months of being enrolled in Medicare.
You may need to get a LHC letter from us as proof of your Medicare
registration date and give this to your private health insurer to
demonstrate your exemption from the loading. You can request a
LHC letter in this form.
The longer you wait the higher the LHC loading will be. For more
information about LHC, go to
www.
privatehealth.gov.au
My Health Record
A My Health Record is an online summary of an individual’s health
information. Individuals listed on this form can get a My Health
Record when enrolled in Medicare. Questions relating to My Health
Record are outlined in
Part C
(Enrolling a newborn child) and
Part D
(My Health Record) of this form.
For more information about My Health Record, go to
www.
digitalhealth.gov.au
Individual healthcare identifiers
An Individual Healthcare Identifier (IHI) is a unique 16 digit number
used to identify an individual for healthcare purposes in Australia.
No clinical information is linked to the identifier. You do not need to
remember your IHI to receive healthcare. You may already have an
IHI.
For more information about IHIs go to
www.
servicesaustralia.gov.au/hi
Aboriginal and Torres Strait Islander Australian
The Aboriginal and Torres Strait Islander Australian question is
voluntary and will not affect your application. If you do answer, the
information will help us to continue to improve services to Aboriginal
and Torres Strait Islander Australians.
Australian South Sea Islander
The Australian South Sea Islander question is voluntary and will not
affect your application. If you do answer, the information will help us
to continue to improve services to people of Australian South Sea
Islander descent.
Australian South Sea Islanders are the descendants of Pacific
Islander labourers brought from the Western Pacific in the 19th
Century.
For more information
For more information about Medicare enrolments, go to
www.
servicesaustralia.gov.au/enrolmedicare
or call
132 011
Monday
to Friday, 8:30 am to 5 pm, Australian Eastern Standard Time. To
speak to us in your language call
131 450
.
Medicare enrolment form
(MS004)
MS004.2403
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Filling in this form
You can complete this form on your computer using Adobe Acrobat
Reader, and some browsers, or you can print it.
If you have a printed form:
•
Use black or blue pen.
•
Print in BLOCK LETTERS.
•
Where you see a box like this
Go to 1
skip to the question
number shown.
Type of enrolment
1
What are you using this form for?
Enrolling in Medicare for the first time or
a returning visitor from a country with a
Reciprocal Health Care Agreement with
Australia, previously enrolled in Medicare
(for persons aged 12 months and older and
newborn children born overseas)
Go to Part A
Question 2
Re-enrolling in Medicare or
extending Medicare eligibility
(for example, resident returning to Australia,
Interim or Reciprocal Medicare card holders
who have not left Australia)
Go to Part A
Question 3
Enrolling a newborn child
(for children aged up to their 1st birthday
who are born in Australia)
Go to Part C
Registering for a My Health Record
The My Health Record questions must be
completed for persons listed in
Part A
and
Part B
of this form.
Note
: If you are using this
form to enrol a newborn child, you do
not need to complete
Part D
.
Go to Part D
Part A
– Enrolling in Medicare for the first time,
re-enrolling in Medicare or extending
Medicare eligibility
2
Enrolling in Medicare for the first time
Documents are required for each person, include copies of both
the front and back:
Australian citizen
•
valid Australian passport, or
•
Australian birth certificate, and
•
2 residency documents (see page 3).
If enrolling as a family, only 2 residency
documents are needed for the application.
Child born overseas to an Australian citizen
•
a birth certificate and a valid Australian
passport, or
•
a birth certificate, foreign passport, and
Australian citizenship certificate.
New Zealand citizen residing in Australia
•
a New Zealand passport, and
•
2 residency documents (see page 3).
If enrolling as a family, only 2 residency
documents are needed for the application.
Permanent resident
(but not an Australian citizen)
•
a passport or valid ImmiCard, and
•
proof of permanent residency from the
Department of Home Affairs
•
residency documents (see page 3) if your
permanent residency visa was granted more
than 12 months ago.
Have applied for permanent residency/permanent
protection visa
•
a passport or valid ImmiCard, and
•
proof that an application for permanent
residency has been lodged with the
Department of Home Affairs (and
information about the category of visa that
has been applied for), and
•
proof of a valid visa.
If your visa does not let you work in Australia, you
need to provide documents that prove you have a
parent, spouse, de facto or child who lives in
Australia and is either an Australian citizen, a
New Zealand citizen or a permanent resident of
Australia.
Visitor from a country that has a Reciprocal Health
Care Agreement with Australia
•
a passport or travel document
•
proof of a valid visa
•
proof of overseas health insurance
•
documents to prove your country of
residence.
Go to
www.
servicesaustralia.gov.au/rhca
for
residency documents.
Not all of the above information is required for
each visitor to Australia. For more information,
go to
www.
servicesaustralia.gov.au/rhca
If your visit to Australia is for less than 3 months,
we will not send you a physical card. We will send
you a letter with your Medicare number. You will
need to give us an Australian mailing address in
this form. If you do not have an Australian address
we will not be able to send you your Medicare
number.
Other visa holders – covered by Ministerial Order
•
passport, travel document or valid
ImmiCard, and
•
proof of a valid visa from the Department of
Home Affairs.
MCA0MS004 2403
MS004.2403
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3
Re-enrolling in Medicare or extending Medicare eligibility
Documents are required for each person, include copies of both
the front and back.
Returning to reside in Australia permanently
For example:
•
Australian citizens returning to live in Australia after
more than 5 years
•
New Zealand citizens or permanent residents returning
to live in Australia after 12 months or more.
•
a passport, and
•
2 residency documents (see page 3).
If enrolling as a family, only 2 residency
documents are needed for the application.
Extend my Medicare eligibility
For Reciprocal Medicare card holders who have not left
Australia or Interim Medicare card holders who wish to
apply for an extension.
•
a passport or valid ImmiCard, and
•
proof of a valid visa, and
•
evidence from the Department of Home
Affairs that you have applied for another visa
(if relevant).
If you have lodged an appeal against a refused
visa decision, you need to provide evidence of
the appeal. The evidence must be dated within
the last 2 years.
Residency documents
Residency documents can be made up of 2 documents from
Australia or 1 document from Australia and 1 from where the person
last lived. Documents must be dated within the last 6 months. If you
do not have these documents, call us on
132 011
. We will talk to you
about other options.
Documents from another country
•
proof you sold your property
•
proof you ended your lease
•
proof you ended your employment
•
proof you moved household goods or furniture
•
proof you closed your bank account
•
proof you cancelled health, property or contents insurance.
Documents from Australia
•
proof of purchase of property, and gas or electricity account in
the same name
•
proof of rental or lease agreement, and gas or electricity
account in the same name
•
proof of your employment
•
proof your child is enrolled in childcare, school or university
•
proof you have a current bank account in Australia
•
proof of health, property or contents insurance.
Medicare contact person
You will be the nominated contact person who we will send the
Medicare card(s) and general information to on behalf of everyone
listed on the Medicare card(s).
Your details
4
Mr
Mrs
Miss
Ms
Other
Family name
First given name
Second given name
5
Have you ever used or been known by another name?
No
Yes
Give details of your previous name
6
Date of birth (DD MM YYYY)
7
Gender
Male
Female
8
Postal address
Postcode
9
Contact phone number (including area code)
10
Do you need an interpreter?
No
Yes
What is your preferred spoken language
Secondary language (if applicable)
11
Individual Healthcare Identifier (if applicable)
8 0 0 3 6 0
MS004.2403
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12
If you:
•
are enrolling in Medicare for the first time
Go to 13
•
are re-enrolling in Medicare or wanting to extend your
Medicare eligibility
Your previous Medicare card number (if known)
Ref no.
Go to 13
•
only
want to enrol a dependant in Medicare
(for example, a newborn child born overseas or a
child aged 12 months or older).
Your current Medicare card number
Ref no.
Go to 21
13
Are you of Aboriginal or Torres Strait Islander Australian
descent?
If you are of both Aboriginal and Torres Strait Islander Australian
descent, tick both ‘Yes’ boxes.
No
Yes – Aboriginal Australian
Yes – Torres Strait Islander Australian
14
Are you of Australian South Sea Islander descent?
No
Yes
15
Have you previously lived overseas?
No
Go to 20
Yes
Go to next question
16
Previous country of residence before arriving in Australia
17
How long were you residing in that country?
(state the total number of years and/or months)
years months
18
Date of arrival in Australia (DD MM YYYY)
19
Do you have plans to reside in Australia permanently?
No
Planned date of departure (if known) (DD MM YYYY)
Yes
20
Do you require a Lifetime Health Cover letter?
(For more information, see page 1 of this form)
No
Yes
Bank account details
21
All payments are made through Electronic Funds Transfer
(EFT). Payments
cannot
be made via EFT if the nominated
account has restrictions on EFT deposits.
We cannot record bank account details for children
under
14 years of age
.
Do not include
an account used exclusively for funding from
the National Disability Insurance Scheme.
Name of bank, building society or credit union
(Australian financial institutions only)
Branch number (BSB)
Account number (this may not be the card number)
Account held in the name(s) of
Privacy notice
22
The privacy and security of your personal information is
important to us, and is protected by law. We collect this
information so we can process and manage your applications
and payments, and provide services to you. We only share your
information with other parties where you have agreed, or where
the law allows or requires it. For more information, go to
www.
servicesaustralia.gov.au/privacypolicy
MS004.2403
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Declaration
23
I declare that
:
•
any additional person listed in Part B of this form, aged
14 years or older, has reviewed their personal information
provided.
•
I have read and understood the Privacy notice.
•
I am aware of my legal obligation to provide true and
accurate information.
•
the information I have provided in this form is complete and
correct.
I consent to
:
•
Services Australia validating identity documents I provide
with the issuing authority.
I authorise for
:
•
payments to be made into the bank account I nominated in
this form.
I understand that
:
•
Services Australia is collecting and using my healthcare
identifier for purposes of establishing and maintaining an
accurate record of healthcare identifiers.
•
if I am enrolled in Medicare, I will be registered for the
Medicare Safety Nets as an individual.
•
identification documents provided to Services Australia will
be checked with the issuing authority to confirm validity.
The documents are subject to Services Australia’s
compliance and audit processes.
•
I must notify Services Australia of any change(s) to this
information.
•
giving false or misleading information is a serious offence.
Your full name
I have read, understood and agree to the above.
Date (DD MM YYYY)
What to do now
24
Are there other people to be enrolled on your Medicare card?
No
Go to Part D
and answer the My Health Record
questions before returning this form.
Yes
Go to Part B
If one or more of the other people enrolling have a
different immigration type/status to you or a
different visa entitlement end date, they cannot be
listed on the same Medicare card. They will need
to complete a separate Medicare enrolment form.
Part B
– Other people to be enrolled or re-enrolled
in Medicare, or have their Medicare
eligibility extended
Additional person 1
25
Has additional person 1 previously been enrolled in Medicare?
No
Yes
Previous Medicare card number (if known)
Ref no.
26
Mr
Mrs
Miss
Ms
Other
Family name
First given name
Second given name
27
Has this person ever used or been known by another name?
No
Yes
Give details of their previous name
28
Date of birth (DD MM YYYY)
29
Gender
Male
Female
30
Contact phone number (including area code)
– to be completed if person 15 years or older
Email – to be completed if person 15 years or older
31
Does this person need an interpreter?
No
Yes
What is their preferred spoken language
Secondary language (if applicable)
32
Individual Healthcare Identifier (if applicable)
8 0 0 3 6 0
33
Is this person of Aboriginal or Torres Strait Islander Australian
descent?
If they are of both Aboriginal and Torres Strait Islander Australian
descent, tick both ‘Yes’ boxes.
No
Yes – Aboriginal Australian
Yes – Torres Strait Islander Australian
MS004.2403
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34
Is this person of Australian South Sea Islander descent?
No
Yes
35
Has this person previously lived overseas?
No
Go to 40
Yes
Go to next question
36
Previous country of residence before arriving in Australia
37
How long was this person residing in that country?
(state total number of years and/or months)
years months
38
Date of arrival in Australia (DD MM YYYY)
39
Does this person have plans to reside in Australia permanently?
No
Planned date of departure (if known) (DD MM YYYY)
Yes
40
Does this person require a Lifetime Health Cover letter?
(For more information, see page 1 of this form)
No
Yes
41
To be completed by additional person 1 if 14 years or older
Do you want payments to be made into the nominated bank
account at question 21?
No
Go to 42
Yes
I authorise for payments to be made into the bank
account at question 21
Additional person 1 full name
Go to 43
42
Provide your bank account details
Name of bank, building society or credit union
(Australian financial institutions only)
Branch number (BSB)
Account number (this may not be the card number)
Account held in the name(s) of
I authorise for payments to be made into the bank account I
have nominated above.
Additional person 1 full name
43
To be completed by additional person 1 if 15 years or older
Privacy notice
The privacy and security of your personal information is
important to us, and is protected by law. We collect this
information so we can process and manage your applications
and payments, and provide services to you. We only share your
information with other parties where you have agreed, or where
the law allows or requires it. For more information, go to
www.
servicesaustralia.gov.au/privacypolicy
Declaration of additional person 1
If additional person 1 is
15 years or older
they must
complete this declaration.
I declare that
:
•
I have read and understood the Privacy notice.
•
I am aware of my legal obligation to provide true and
accurate information.
•
the information I have provided in this form is complete and
correct.
I consent to
:
•
Services Australia validating identity documents I provide
with the issuing authority.
•
Services Australia collecting my personal information in
this form.
I understand that
:
•
identification documents provided to Services Australia will
be checked with the issuing authority to confirm validity.
The documents are subject to Services Australia’s
compliance and audit processes.
•
if I am enrolled in Medicare, I will be registered for the
Medicare Safety Nets as an individual.
•
Services Australia is collecting and using my healthcare
identifier for purposes of establishing and maintaining an
accurate record of healthcare identifiers.
•
I must notify Services Australia of any change(s) to this
information.
•
giving false or misleading information is a serious offence.
Additional person 1 full name
I have read, understood, and agree to the above
If more than one additional person,
go to 44
, if not
go to 101
MS004.2403
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Additional person 2
44
Has additional person 2 previously been enrolled in Medicare?
No
Yes
Previous Medicare card number (if known)
Ref no.
45
Mr
Mrs
Miss
Ms
Other
Family name
First given name
Second given name
46
Has this person ever used or been known by another name?
No
Yes
Give details of their previous name
47
Date of birth (DD MM YYYY)
48
Gender
Male
Female
49
Contact phone number (including area code)
– to be completed if person 15 years or older
Email – to be completed if person 15 years or older
50
Does this person need an interpreter?
No
Yes
What is their preferred spoken language
Secondary language (if applicable)
51
Individual Healthcare Identifier (if applicable)
8 0 0 3 6 0
52
Is this person of Aboriginal or Torres Strait Islander Australian
descent?
If they are of both Aboriginal and Torres Strait Islander Australian
descent, tick both ‘Yes’ boxes.
No
Yes – Aboriginal Australian
Yes – Torres Strait Islander Australian
53
Is this person of Australian South Sea Islander descent?
No
Yes
54
Has this person previously lived overseas?
No
Go to 59
Yes
Go to next question
55
Previous country of residence before arriving in Australia
56
How long was this person residing in that country?
(state total number of years and/or months)
years months
57
Date of arrival in Australia (DD MM YYYY)
58
Does this person have plans to reside in Australia permanently?
No
Planned date of departure (if known) (DD MM YYYY)
Yes
59
Does this person require a Lifetime Health Cover letter?
(For more information, see page 1 of this form)
No
Yes
60
To be completed by additional person 2 if 14 years or older
Do you want payments to be made into the nominated bank
account at question 21?
No
Go to 61
Yes
I authorise for payments to be made into the bank
account at question 21
Additional person 2 full name
Go to 62
61
Provide your bank account details
Name of bank, building society or credit union
(Australian financial institutions only)
Branch number (BSB)
Account number (this may not be the card number)
Account held in the name(s) of
I authorise for payments to be made into the bank account I
have nominated above.
Additional person 2 full name
MS004.2403
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62
To be completed by additional person 2 if 15 years or older
Privacy notice
The privacy and security of your personal information is
important to us, and is protected by law. We collect this
information so we can process and manage your applications
and payments, and provide services to you. We only share your
information with other parties where you have agreed, or where
the law allows or requires it. For more information, go to
www.
servicesaustralia.gov.au/privacypolicy
Declaration of additional person 2
If additional person 2 is
15 years or older
they must
complete this declaration.
I declare that
:
•
I have read and understood the Privacy notice.
•
I am aware of my legal obligation to provide true and
accurate information.
•
the information I have provided in this form is complete and
correct.
I consent to
:
•
Services Australia validating identity documents I provide
with the issuing authority.
•
Services Australia collecting my personal information in
this form.
I understand that
:
•
identification documents provided to Services Australia will
be checked with the issuing authority to confirm validity.
The documents are subject to Services Australia’s
compliance and audit processes.
•
if I am enrolled in Medicare, I will be registered for the
Medicare Safety Nets as an individual.
•
Services Australia is collecting and using my healthcare
identifier for purposes of establishing and maintaining an
accurate record of healthcare identifiers.
•
I must notify Services Australia of any change(s) to this
information.
•
giving false or misleading information is a serious offence.
Additional person 2 full name
I have read, understood, and agree to the above
If more than 2 additional people,
go to 63
, if not
go to 101
Additional person 3
63
Has additional person 3 previously been enrolled in Medicare?
No
Yes
Previous Medicare card number (if known)
Ref no.
64
Mr
Mrs
Miss
Ms
Other
Family name
First given name
Second given name
65
Has this person ever used or been known by another name?
No
Yes
Give details of their previous name
66
Date of birth (DD MM YYYY)
67
Gender
Male
Female
68
Contact phone number (including area code)
– to be completed if person 15 years or older
Email – to be completed if person 15 years or older
69
Does this person need an interpreter?
No
Yes
What is their preferred spoken language
Secondary language (if applicable)
70
Individual Healthcare Identifier (if applicable)
8 0 0 3 6 0
71
Is this person of Aboriginal or Torres Strait Islander Australian
descent?
If they are of both Aboriginal and Torres Strait Islander Australian
descent, tick both ‘Yes’ boxes.
No
Yes – Aboriginal Australian
Yes – Torres Strait Islander Australian
72
Is this person of Australian South Sea Islander descent?
No
Yes
MS004.2403
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73
Has this person previously lived overseas?
No
Go to 78
Yes
Go to next question
74
Previous country of residence before arriving in Australia
75
How long was this person residing in that country?
(state total number of years and/or months)
years months
76
Date of arrival in Australia (DD MM YYYY)
77
Does this person have plans to reside in Australia permanently?
No
Planned date of departure (if known) (DD MM YYYY)
Yes
78
Does this person require a Lifetime Health Cover letter?
(For more information, see page 1 of this form)
No
Yes
79
To be completed by additional person 3 if 14 years or older
Do you want payments to be made into the nominated bank
account at question 21?
No
Go to 80
Yes
I authorise for payments to be made into the bank
account at question 21
Additional person 3 full name
Go to 81
80
Provide your bank account details
Name of bank, building society or credit union
(Australian financial institutions only)
Branch number (BSB)
Account number (this may not be the card number)
Account held in the name(s) of
I authorise for payments to be made into the bank account I
have nominated above.
Additional person 3 full name
81
To be completed by additional person 3 if 15 years or older
Privacy notice
The privacy and security of your personal information is
important to us, and is protected by law. We collect this
information so we can process and manage your applications
and payments, and provide services to you. We only share your
information with other parties where you have agreed, or where
the law allows or requires it. For more information, go to
www.
servicesaustralia.gov.au/privacypolicy
Declaration of additional person 3
If additional person 3 is
15 years or older
they must
complete this declaration.
I declare that
:
•
I have read and understood the Privacy notice.
•
I am aware of my legal obligation to provide true and
accurate information.
•
the information I have provided in this form is complete and
correct.
I consent to
:
•
Services Australia validating identity documents I provide
with the issuing authority.
•
Services Australia collecting my personal information in
this form.
I understand that
:
•
identification documents provided to Services Australia will
be checked with the issuing authority to confirm validity.
The documents are subject to Services Australia’s
compliance and audit processes.
•
if I am enrolled in Medicare, I will be registered for the
Medicare Safety Nets as an individual.
•
Services Australia is collecting and using my healthcare
identifier for purposes of establishing and maintaining an
accurate record of healthcare identifiers.
•
I must notify Services Australia of any change(s) to this
information.
•
giving false or misleading information is a serious offence.
Additional person 3 full name
I have read, understood, and agree to the above
If more than 3 additional people,
go to 82
, if not
go to 101
MS004.2403
10 of 17
Additional person 4
82
Has additional person 4 previously been enrolled in Medicare?
No
Yes
Previous Medicare card number (if known)
Ref no.
83
Mr
Mrs
Miss
Ms
Other
Family name
First given name
Second given name
84
Has this person ever used or been known by another name?
No
Yes
Give details of their previous name
85
Date of birth (DD MM YYYY)
86
Gender
Male
Female
87
Contact phone number (including area code)
– to be completed if person 15 years or older
Email – to be completed if person 15 years or older
88
Does this person need an interpreter?
No
Yes
What is their preferred spoken language
Secondary language (if applicable)
89
Individual Healthcare Identifier (if applicable)
8 0 0 3 6 0
90
Is this person of Aboriginal or Torres Strait Islander Australian
descent?
If they are of both Aboriginal and Torres Strait Islander Australian
descent, tick both ‘Yes’ boxes.
No
Yes – Aboriginal Australian
Yes – Torres Strait Islander Australian
91
Is this person of Australian South Sea Islander descent?
No
Yes
92
Has this person previously lived overseas?
No
Go to 97
Yes
Go to next question
93
Previous country of residence before arriving in Australia
94
How long was this person residing in that country?
(state total number of years and/or months)
years months
95
Date of arrival in Australia (DD MM YYYY)
96
Does this person have plans to reside in Australia permanently?
No
Planned date of departure (if known) (DD MM YYYY)
Yes
97
Does this person require a Lifetime Health Cover letter?
(For more information, see page 1 of this form)
No
Yes
98
To be completed by additional person 4 if 14 years or older
Do you want payments to be made into the nominated bank
account at question 21?
No
Go to 99
Yes
I authorise for payments to be made into the bank
account at question 21
Additional person 4 full name
Go to 100
99
Provide your bank account details
Name of bank, building society or credit union
(Australian financial institutions only)
Branch number (BSB)
Account number (this may not be the card number)
Account held in the name(s) of
I authorise for payments to be made into the bank account I
have nominated above.
Additional person 4 full name
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100
To be completed by additional person 4 if 15 years or older
Privacy notice
The privacy and security of your personal information is
important to us, and is protected by law. We collect this
information so we can process and manage your applications
and payments, and provide services to you. We only share your
information with other parties where you have agreed, or
where the law allows or requires it. For more information, go
to
www.
servicesaustralia.gov.au/privacypolicy
Declaration of additional person 4
If additional person 4 is
15 years or older
they must
complete this declaration.
I declare that
:
•
I have read and understood the Privacy notice.
•
I am aware of my legal obligation to provide true and
accurate information.
•
the information I have provided in this form is complete
and correct.
I consent to
:
•
Services Australia validating identity documents I provide
with the issuing authority.
•
Services Australia collecting my personal information in
this form.
I understand that
:
•
identification documents provided to Services Australia
will be checked with the issuing authority to confirm
validity. The documents are subject to Services Australia’s
compliance and audit processes.
•
if I am enrolled in Medicare, I will be registered for the
Medicare Safety Nets as an individual.
•
Services Australia is collecting and using my healthcare
identifier for purposes of establishing and maintaining an
accurate record of healthcare identifiers.
•
I must notify Services Australia of any change(s) to this
information.
•
giving false or misleading information is a serious offence.
Additional person 4 full name
I have read, understood, and agree to the above
If more than 4 additional people, complete
Part B
on another
Medicare enrolment form.
101
Do you need a duplicate card?
(A duplicate card means you will get a second card with the
same details. We can only issue one extra card.)
No
Yes
Register your family for the Medicare Safety Nets
Medicare Safety Nets can help lower your costs for out of hospital
services.
You can choose to register as a family to combine your costs. This
means you are likely to reach the Medicare Safety Net threshold
sooner.
For Medicare Safety Net purposes, a family is any of these:
•
a married couple, not separated, with or without dependants
•
a couple in a de facto relationship, with or without
dependants
•
a single person with dependants
A dependant is someone the family supports financially and is a
child under 16 years or a fulltime student between 16 and 25
years.
To find out how to register, go to
www.
servicesaustralia.gov.au/safetynet
Go to Part D and answer the My Health Record questions
before returning this form.
MS004.2403
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Part C
– Enrolling a newborn child
A child is considered to be a ‘newborn’ up
until the day of their 1st birthday.
You can enrol a newborn child born in Australia using Medicare
online accounts. For help setting up online access, go to
www.
servicesaustralia.gov.au/selfservice
or complete
Part C
.
If your newborn child was born overseas, complete
Part A
and
then
Part B
.
102
You need to provide
one
of the following documents to confirm
your relationship with the newborn child:
•
a birth certificate, or
•
the back page of the
Newborn Child
Declaration (FA081)
form issued by the
hospital or birthing centre, or
•
doctor/midwife’s declaration of birth, or
•
court order or other legal documentation.
Your details
103
Your Medicare card number
Ref no.
104
Mr
Mrs
Miss
Ms
Other
Family name
First given name
Second given name
105
Have you ever used or been known by another name?
No
Yes
Give details of your previous name
106
Your date of birth (DD MM YYYY)
107
Your relationship to this child
Birth mother
Biological father
Other
Give details
108
Postal address
Postcode
109
Contact phone number (including area code)
110
Do you need an interpreter?
No
Yes
What is your preferred spoken language
Secondary language (if applicable)
111
Do you have a partner?
No
Go to 121
Yes
112
Is your partner listed on your Medicare card?
No
Go to 114
Yes
Go to next question
113
Do you need a duplicate card?
(Only one duplicate card can be issued)
No
Go to 121
Yes
Go to 121
114
Does your partner want the newborn child to be added to their
Medicare card?
No
Go to 121
Yes
You and your partner are both required to complete
question 129
Go to next question
115
Your partner’s Medicare card number
Ref no.
116
Your partner’s name
Mr
Mrs
Miss
Ms
Other
Family name
First given name
Second given name
Medicare enrolment form
(MS004)
MS004.2403
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117
Has your partner ever used or been known by another name?
No
Yes
Give details of your partner’s previous name
118
Your partner’s date of birth (DD MM YYYY)
119
Your partner’s relationship to this child
Birth mother
Biological father
Other
Give details
120
Do you want your partner added to your Medicare Safety Net
family registration?
No
Yes
Your partner’s Medicare Card Number
Ref no.
121
Do you want your newborn child added to your Medicare
Safety Net family registration?
No
Yes
If you want to add anyone else to your Medicare Safety Net
family registration, call us on 132 011 or complete the
Medicare Safety Net registration and amendment for
couples and families (MS016)
form. To download the form,
go to
www.
servicesaustralia.gov.au/ms016
Child details
If you are enrolling more than one newborn child (such as multiple
births), complete and return a separate
Part C
for each child.
122
Child’s name
Family name
First given name
Second given name
123
Child’s date of birth (DD MM YYYY)
124
Child’s sex
Male
Female
125
Is your child of Aboriginal or Torres Strait Islander Australian
descent?
If they are of both Aboriginal and Torres Strait Islander
Australian descent, tick both ‘Yes’ boxes.
No
Yes – Aboriginal Australian
Yes – Torres Strait Islander Australian
126
Is your child of Australian South Sea Islander descent?
No
Yes
127
Read
this before answering the question.
You must have parental responsibility for this child to make
decisions about My Health Record. You can request or
cancel a My Health Record at any time. For more
information, go to
www.
digitalhealth.gov.au
Do you want us to give your newborn child a My Health
Record?
No
This child will not get a record
Go to next question
Yes
Go to next question
MS004.2403
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Privacy notice
128
The privacy and security of your personal information is
important to us, and is protected by law. We collect this
information so we can process and manage your applications
and payments, and provide services to you. We only share
your information with other parties where you have agreed, or
where the law allows or requires it. For more information, go
to
www.
servicesaustralia.gov.au/privacypolicy
The My Health Record System Operator will collect personal
information in this form from Services Australia for the
purpose of the My Health Record system and may also use
and disclose this information as required or authorised by law,
only within Australia, including the
My Health Records Act 2012
and
Privacy Act 1988
.
For more information, see the My Health Record System
Operator’s privacy policy at
www.
digitalhealth.gov.au/privacy
Declaration
129
I declare that
:
•
I have read and understood the Privacy notice.
•
I am aware of my legal obligation to provide true and
accurate information.
•
the information I have provided in this form is complete
and correct.
I consent to
:
•
Services Australia validating identity documents I provide
with the issuing authority.
I understand that
:
•
I must notify Services Australia of any change(s) to this
information.
•
identification documents provided to Services Australia
will be checked with the issuing authority to confirm
validity. The documents are subject to Services Australia’s
compliance and audit processes.
•
giving false or misleading information is a serious offence.
Your full name
I have read, understood and agree to the above.
Date (DD MM YYYY)
Partner’s full name
I have read, understood and agree to the above.
Date (DD MM YYYY)
You do not need to answer any more questions.
This form can be returned.
For newborn child enrolments only
Return
Part C
and any supporting documents by:
•
to
MES@servicesaustralia.gov.au
There may be risks with sending personal information
through unsecured networks or email channels.
Make sure your documents are:
–
in PDF, JPG, PNG, GIF or BMP format
–
not password protected, or in a WinZip or RAR file
–
no larger than 5MB for each document
–
no larger than 10MB in total for all the documents.
To help us process your request, include
Enrolment
in the
email subject line.
•
post to
Services Australia
Medicare
PO Box 7856
CANBERRA BC ACT 2610
Save
MS004.2403
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Part D
– My Health Record
A My Health Record is an online summary of an individual’s health
information. It can be accessed at any time by the individual and
their healthcare providers.
You and any other person enrolling in Medicare on this form can
get a My Health Record.
We cannot process the following My Health Record questions if
you or the additional people have:
•
an existing My Health Record
•
cancelled a My Health Record
•
opted out of getting a My Health Record.
For more information or to make changes to previous My Health
Record preferences, go to
www.
digitalhealth.gov.au
or call the
My Health Record System Operator on
1800 723 471
.
Medicare contact person (you)
130
Are you using this form to enrol yourself in Medicare?
No
Go to 132
Yes
Go to next question
131
Do you want a My Health Record?
No –
Do not
give me a My Health Record
Yes – Give me a My Health Record
132
Are you using this form to enrol additional people in Medicare?
No
Go to 148
Yes
Go to
Additional people
below
Additional people
Read this information before completing the questions for the
additional people listed in Part B of this form
You must have parental responsibility to complete questions for
additional people under 14 years old.
If the additional person is 14 years or older, they must:
•
answer the question relating to whether or not they want a
My Health Record
•
read the Privacy notice at question 148
•
complete their declaration.
Additional person 1
133
Name (as stated in
Part B
of this form)
Family name
First given name
Second given name
134
Do you want us to give this person a My Health Record?
This question must be completed by the additional person if
they are 14 years or older.
No –
Do not
give this person a My Health Record
Yes – Give this person a My Health Record
135
Additional person 1 declaration (if 14 years or older)
I declare that
:
•
the information I have provided at question 134 is
complete and correct.
•
I have read the Privacy notice at question 148.
Additional person 1 full name
I have read, understood and agree to the above.
Date (DD MM YYYY)
136
Are there other additional people listed in
Part B
of this form?
No
Go to 148
Yes
Go to next question
MS004.2403
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Additional person 2
137
Name (as stated in
Part B
of this form)
Family name
First given name
Second given name
138
Do you want us to give this person a My Health Record?
This question must be completed by the additional person if
they are 14 years or older.
No –
Do not
give this person a My Health Record
Yes – Give this person a My Health Record
139
Additional person 2 declaration (if 14 years or older)
I declare that
:
•
the information I have provided at question 138 is
complete and correct.
•
I have read the Privacy notice at question 148.
Additional person 2 full name
I have read, understood and agree to the above.
Date (DD MM YYYY)
140
Are there other additional people listed in
Part B
of this form?
No
Go to 148
Yes
Go to next question
Additional person 3
141
Name (as stated in
Part B
of this form)
Family name
First given name
Second given name
142
Do you want us to give this person a My Health Record?
This question must be completed by the additional person if
they are 14 years or older.
No –
Do not
give this person a My Health Record
Yes – Give this person a My Health Record
143
Additional person 3 declaration (if 14 years or older)
I declare that
:
•
the information I have provided at question 142 is
complete and correct.
•
I have read the Privacy notice at question 148.
Additional person 3 full name
I have read, understood and agree to the above.
Date (DD MM YYYY)
144
Are there other additional people listed in
Part B
of this form?
No
Go to 148
Yes
Go to next question
MS004.2403
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Additional person 4
145
Name (as stated in
Part B
of this form)
Family name
First given name
Second given name
146
Do you want us to give this person a My Health Record?
This question must be completed by the additional person if
they are 14 years or older.
No –
Do not
give this person a My Health Record
Yes – Give this person a My Health Record
147
Additional person 4 declaration (if 14 years or older)
I declare that
:
•
the information I have provided at question 146 is
complete and correct.
•
I have read the Privacy notice at question 148.
Additional person 4 full name
I have read, understood and agree to the above.
Date (DD MM YYYY)
If more than 4 additional people, complete
Part D
on another
Medicare enrolment form.
Privacy notice
148
The My Health Record System Operator will collect personal
information in this form from Services Australia for the
purpose of the My Health Record system and may also use
and disclose this information as required or authorised by
law,
only within Australia, including the
My Health Records Act 2012
and
Privacy Act 1988
.
For more information, see the My Health Record System
Operator’s privacy policy at
www.
digitalhealth.gov.au/privacy
Declaration
149
I declare that
:
•
I have parental responsibility for the additional people
under 14 years old that I have completed My Health
Record questions for.
•
I have read and understood the Privacy notice.
•
I am aware of my legal obligation to provide true and
accurate information.
•
the information I have provided in this form is complete
and correct.
I consent to
:
•
Services Australia validating identity documents I provide
with the issuing authority.
I understand that
:
•
I must notify Services Australia of any change(s) to this
information.
•
identification documents provided to Services Australia
will be checked with the issuing authority to confirm
validity. The documents are subject to Services Australia’s
compliance and audit processes.
•
giving false or misleading information is a serious offence.
Your full name
I have read, understood and agree to the above.
Date (DD MM YYYY)
Returning this form
Return this form and any supporting documents by:
•
to
MES@servicesaustralia.gov.au
There may be risks with sending personal information through
unsecured networks or email channels.
Make sure your documents are:
–
in PDF, JPG, PNG, GIF or BMP format
–
not password protected, or in a WinZip or RAR file
–
no larger than 5MB for each document
–
no larger than 10MB in total for all the documents.
To help us process your request, include
Enrolment
in the
email subject line.
•
post to
Services Australia
Medicare
PO Box 7856
CANBERRA BC ACT 2610
Save
