Incomplete or incorrect Medicare claims forms 011-43010050
Expand allThis page contains the Claimant Declaration text and links to the VG4 form, the Medicare Claim form (MS014) and Standard Letter Templates.
Claimant Declaration
"Do you declare that you have incurred the expenses for the services for which you are claiming and that they are not for the purposes of superannuation or provident account schemes, admission to a friendly society, life insurance, mass immunisation, or health screening and are not connected with the patient's employment?
Do you declare that the services were not provided by or on behalf of the Australian Government, a state, territory or a local governing body or an authority established by a law of the Australian Government, a state or territory?
Do you declare that you have not claimed for dental expenses through private health insurance?
You are aware that the Agency’s Privacy notice is available on our website, www.servicesaustralia.gov.au.
To the best of your knowledge and belief, is all the information disclosed true and correct and you are aware that giving false or misleading information is a serious offence?
Do you authorise Medicare to contact the referring practitioner or the health professional for assessment purposes?"
Forms (staff)
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VG4 form