Medicare Enrolment Application: Applicant(s) Circumstances and Documents Required When To Use This Form
Medicare Enrolment Application: Applicant(s) Circumstances and Documents Required When To Use This Form
Medicare Enrolment Application: Applicant(s) Circumstances and Documents Required When To Use This Form
Documents required
current passport or travel document for each person being
enrolled
valid visa or original visa grant letter for each person being
enrolled
where the applicants do not have permission to work, it is
necessary to provide proof of their relationship with a spouse,
parent or child who is an Australian citizen or an Australian
permanent resident visa holder.
Visitors to Australia
Check that you have answered all the questions you need to answer
and that you have signed and dated this form.
Return your completed form and original or certified documents
to your nearest Medicare Service Centre. For initial enrolments, all
people 15 years of age and over on the application must go with you
to a Medicare Service Centre.
* Visitors from the Republic of Ireland and New Zealand will not be
enrolled in Medicare. Reciprocal Health Care Agreements provide
access as a public patient in a public hospital including outpatient
services and medicines available on prescription, which are
subsidised under the Pharmaceutical Benefits Scheme for medically
necessary treatment.
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Documents required
current passport and valid visa for all applicants.
Further documents may be required.
Mr
Mrs
Family name
Documents required
completed statutory declaration
passports for all people listed on the application
any 2 residency documents from the list below.
Miss
Ms
Other
Residency documents
2 Your sex
Male
Female
/
Postcode
Postcode
Email
@
www.
No
To enable us to make payments into your bank account, you will need
to provide your bank account details at question 54. These details
will be used for future electronic payments, when you claim your
Medicare benefit(s).
You must tell the Department of Human Services immediately if you
change the account that we send your electronic payments to.
Yes
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Applicant(s) details
Ref no.
Person 1
15 Mr
Mrs
Family name
Go to 11
No
Miss
Ms
Other
Entry date
/
Departure date
16 Their sex
Ref no.
Go to 22
No
Entry date
/
Departure date
/ /
21 Their country of residence prior to entering Australia
No
Yes
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Female
/
/
17 Their date of birth
18 Previous Medicare card number (if applicable)
No
Yes
Male
Go to 54
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Person 2
Person 3
25 Mr
Mrs
Family name
Miss
Ms
35 Mr
Other
Mrs
Family name
Miss
26 Their sex
Male
36 Their sex
Female
/
/
27 Their date of birth
28 Previous Medicare card number (if applicable)
Male
Ms
Other
Female
/
/
37 Their date of birth
38 Previous Medicare card number (if applicable)
Ref no.
Ref no.
Yes
Go to 32
Yes
Go to 42
No
No
Entry date
/
Departure date
Entry date
Departure date
/ /
31 Their country of residence prior to entering Australia
/ /
41 Their country of residence prior to entering Australia
No
Yes
No
Yes
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Go to 54
No
Yes
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Go to 54
Person 4
45 Mr
Mrs
Family name
Miss
Ms
Other
No
Go to 57
Yes
46 Their sex
Male
Female
/
/
47 Their date of birth
48 Previous Medicare card number (if applicable)
Yes
Go to 52
No
Entry date
/
Departure date
/ /
51 Their country of residence prior to entering Australia
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Consent
Privacy notice
Persons 14 years of age and over must sign and give their
consent for payments to go into the nominated bank account.
I authorise for:
payments to be made into this account.
Full name of person 1
Signature
Date
/
You can get more information about privacy by going to our website
humanservices.gov.au/privacy or requesting a copy of the full
privacy policy at any of our Service Centres.
www.
Signature
Date
Date
Date
Declaration
57 I declare that:
Date
Comments
/
/
Operator number
Date
Branch
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