Medicare - Your Health 011-40000000

Addition to Batch form

Template to be used when submitting documents to be added to a batch.

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachments.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Addition to Batch form

Adjustment for Patient Claims

Note: use 'Save As' workaround to download/use attachments.

PP045 - Adjustment for Patient Claims

Adjustment on an adjustment for Patient Claims form

To be used by Service Officers when an adjustment has already been processed and a further adjustment is needed for patient claims.

See Latter day adjustments (LDA) and HELD payments for patient claims for more information.

Note: use 'Save As' workaround to download/use attachments.

PP042 - Adjustment on an adjustment for Patient Claims form

Advice of death form (SA116)

See Advice of death form (SA116)

A person can use this form to notify Medicare of the death of an individual.

Note: this form is not mandatory.

Authority to release personal Medicare and Pharmaceutical Benefits Scheme claims information to a third party form

A person must use this form to request Medicare and/or PBS information for a child under 14 years of age.

See Personal information releases on the Services Australia website.

Card Extract Form

To be used by Service Officers to request a Medicare card be extracted before posting.

See also: Medicare cards

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachments.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Card extract form

Cheque extraction request form

When a processing error is identified, Service Officers must fill out a cheque extraction form.

See also: Cheque processing in Medicare

Note: use 'Save As' workaround to download/use attachments.

PP039 - Cheque extraction request form - all states

Child Dental Benefits Schedule enquiry form

To be completed by Service Officers when a person's eligibility cannot be confirmed from details provided by Centrelink/Department of Veterans' Affairs for the Child Dental Benefits Schedule (CDBS).

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachments.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Child Dental Benefits Schedule eligibility enquiry form

Customer enquiry Form

Note: use 'Save As' workaround to download/use attachments.

PP040 -Customer enquiry form

Document Retrieval Form

Used to retrieve processing documents, batches and/or boxes that have been archived.

See Records Management service request mySupport form (mySupport form title: CREATE, TRANSFER OR RETRIEVE A CORPORATE FILE)

Error Explanation Sheet - Medicare Service Centre Network

Error explanation sheet to be completed in conjunction with the processing Service Officer as part of the quality control feedback process for QBBI, Australian Organ Donor Register (AODR) and Continence Aids Payment Scheme (CAPS).

See Error Explanation Sheet - Medicare Service Centre Network on Services Australia Intranet.

Inadvertent Access Form

To be used by Service Officers who have inadvertently accessed the information of a family member, friend, close personal acquaintance, neighbour or other person where a conflict of interest exists.

Note: the Service Officer’s line manager must be notified before completing and lodging this form.

See the Inadvertent Access Form and Inadvertent and/or Authorised Access information on Services Australia Intranet.

Location Specific Practice Number (LSPN) patient declaration form

To be completed by a patient/claimant when they have undergone a diagnostic imaging or radiation oncology procedure at a site that does not have a Location Specific Practice Number (LSPN).

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachments.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Location Specific Practice Number (LSPN) patient declaration form

Medicare Easyclaim enquiry form

To be used when either of the below are experienced. Medicare Easyclaim:

claimants benefits have not reached their bank account
practices encounter issues when transmitting Medicare Easyclaim information

See also: Medicare Easyclaim service

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachments.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Medicare Easyclaim enquiry form

Manual EFT Payment Request Form

To be completed when a manual EFT payment is needed for a Patient, Bulk Bill or Simplified Billing claim.

Note: this form is not to be used for Pay Doctor via Claimant (PDVC) Claims.

PP048 – Manual EFT Payment Request Form

Medicare EFT Dispute form

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachment.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Medicare EFT dispute form

Medicare enrolment form (MS004)

To be completed by a person living in Australia who is:

a migrant
applying for permanent residency
a visitor
a returning Australian citizen
a permanent resident of Norfolk Island
a New Zealand citizen
a returning permanent resident visa holder (previously enrolled)

See the Medicare enrolment form (MS004) on the Services Australia website.

Report Suspected Fraud and Corruption

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Report Suspected Fraud and Corruption form

Medicare Safety Net query form

To be completed by a Service Officer if the system does not reflect the concessional status as stated by the person.

Note: use 'Save As' workaround to download/use attachments.

PP041 -Medicare Safety Net query form

Processing Box Register

Spreadsheet to be used to record processing details of PBS boxes being sent to archives (Iron Mountain).

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachments.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Processing Box Register

Refiling form

Template to be used to label batches, documents and boxes for refiling.

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachments.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Refiling form

Request for cheque trace details

To be completed by a Service Officer when:

a claimant or provider requests cheque trace details on a presented cheque
a claimant requests an EFT trace when they have not received their claimed Medicare benefit(s) into their nominated bank account

Medicare benefit not received (EFT dispute)

Note: use 'Save As' workaround to download/use attachments.

PP043 - Request cheque trace details

Statutory Declaration for Enrolment

To be used in support of an enrolment where there is insufficient residency documents.

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachments.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Statutory Declaration for Enrolment

Stop cheque and reissue payment

See Stop cheque and reissue payment form (MO051) on Services Australia Intranet

Telephone Medicare rebate estimate form

To be completed by a Service Officer when a Medicare rebate estimate has been requested.

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachments.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Telephone Medicare rebate estimate form

Transmittal Sheet

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachments.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Transmittal Sheet

Unable to transmit Medicare Two-way claim form

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachments.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Unable to transmit Medicare Two-way claim form (HW038)

VG4 Form

Used to verify account/receipt details by phone.

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme

Note: use 'Save As' workaround to download/use attachments.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ VG4 Form

Operational Information

Medicare - Your Health 011-40000000

Addition to Batch form

Adjustment for Patient Claims

Adjustment on an adjustment for Patient Claims form

Advice of death form (SA116)

Authority to release personal Medicare and Pharmaceutical Benefits Scheme claims information to a third party form

Card Extract Form

Cheque extraction request form

Child Dental Benefits Schedule enquiry form

Customer enquiry Form

Document Retrieval Form

Error Explanation Sheet - Medicare Service Centre Network

Inadvertent Access Form

Location Specific Practice Number (LSPN) patient declaration form

Medicare Easyclaim enquiry form

Manual EFT Payment Request Form

Medicare EFT Dispute form

Medicare enrolment form (MS004)

Report Suspected Fraud and Corruption

Medicare Safety Net query form

Processing Box Register

Refiling form

Request for cheque trace details

Statutory Declaration for Enrolment

Stop cheque and reissue payment

Telephone Medicare rebate estimate form

Transmittal Sheet

Unable to transmit Medicare Two-way claim form

VG4 Form