Instructions

Application for a
Medicare Entitlement Statement

When to use this form • A person should only apply for a MES for a previous financial
Use this form to ask for a Medicare Entitlement Statement (MES) if year. A person should not apply for a MES for the current
you are not eligible for Medicare and want to claim the Medicare levy financial year unless they are leaving Australia and will be
exemption. submitting a final income tax return before the end of the
financial year.
If you were not eligible for Medicare, you might be exempt from
paying the Medicare levy in your tax return. • If a tax agent prepares the application, the tax agent must
complete the tax agent details in this application form.
A MES tells you the period during a financial year that you were not
eligible for Medicare. Documents required
For the purpose of this form, the applicant is the person who is You will need to give us a certified copy of the photo page of your
applying for the Medicare Entitlement Statement. passport to prove your identity.
You may also need to give us a certified copy of your:
Persons not eligible for Medicare
• current visa
You can get a statement if you were not eligible for Medicare for all
or part of a financial year. • evidence showing you had applied for permanent residency
Before you apply for a statement, check that you were not eligible for • evidence showing your application for permanent residency had
Medicare. Even if you do not have a Medicare card, you may still been refused or withdrawn
have been eligible. • evidence from the Administrative Appeals Tribunal, Federal
If you were eligible for Medicare for the whole financial year you Court or High Court showing you appealed the decision to
cannot get a statement. refuse your application for permanent residency
You may get a statement if you were either: • evidence that your appeal for Ministerial Intervention against the
decision to refuse your permanent residency application is being
• an Australian permanent resident and lived outside Australia for considered
12 months or more
• European Health Insurance Card or other proof of health
• a temporary visa holder and you had not applied for permanent insurance.
residence, excluding Skilled Work Regional visa and Skilled
Employer Sponsored Regional visa holders Your proof of health insurance must show an expiry date if you live in
either:
• a temporary visa holder, and you are not eligible for Medicare
under a Reciprocal Health Care Agreement • Italy
• a New Zealand citizen who spent less than 6 months in • the Netherlands
Australia within a 12 month period • Norway
• an Australian citizen living overseas for 5 years or more. • Belgium
For more information, go to • Slovenia.
servicesaustralia.gov.au/medicareentitlement
www.

Certified copies
How to apply A certified copy means an authorised person has endorsed the copy
• You must get a new statement each year you claim a Medicare of your original document. They must have seen the original.
levy exemption. Just because you claimed the exemption
before, does not mean you will get it every year. Who can certify documents?
• We will process your application. It may take up to 6 weeks to A number of people can certify documents. Examples include:
process your application if you apply between July and November. • legal practitioners
This is because we get a lot of applications at that time. • medical practitioners
• We will write to you if we do not approve your application or • pharmacists
need more information.
• police officers
• If we approve your application, we will send your statement to
the address you tell us in the form. • justice of the peace.
• You will need to tell the Australian Taxation Office (ATO) you For a complete list of people, go to ag.gov.au/Publications/
www.

have a MES when you do your income tax return. You need your Statutory-declarations/Pages/List-of-authorised-witnesses.aspx
statement before you can start. Keep the statement for your
records. For more information
• The ATO will decide if you need to pay the Medicare levy. Go to servicesaustralia.gov.au/medicareentitlement
www.

MS015.2008 1 of 4
 Application for a
Medicare Entitlement Statement (MS015)

6 Provide the applicant’s name as it appears on their passport

Filling in this form
You can complete this form on your computer, print and sign it. Dr Mr Mrs Miss Ms Other
If you have a printed form: Family name
• Use black or blue pen.
• Print in BLOCK LETTERS. First given name
• Where you see a box like this Go to 1 skip to the question
number shown.
Second given name
1 Is a tax agent completing this application on the applicant’s
behalf?
No Go to 5 7 Applicant’s gender
Yes ✔ Male
2 Does the applicant give permission for their tax agent to supply Female
and receive information related to this application? 8 Applicant’s date of birth
No
/ /
Yes ✔
9 Applicant’s daytime phone number
Tax agent’s details ( )
When sending documents by email, documents: Applicant’s email
• must be in PDF format
• must not be password protected, and
• must not be larger than 10 megabytes 10 Applicant’s residential address in Australia
If you are sending applications for multiple applicants, a separate
email must be sent for each applicant. If the applicant has
multiple applications for different financial years, they can be sent
in one email.
Postcode
Questions 3 and 4 must be completed by the tax agent.
3 Name of company 11 What postal address would the applicant like all correspondence
sent to?
ACCOUNTS NEXTGEN PTY LTD
PO BOX 13266
Name of tax agent who is completing this application LAW COURTS
SHIVA RAMANATHAN VIC Postcode 8010
Tax agent’s daytime phone number Country (if not Australia)
( 03 ) 9015 8540
12 Is the postal address provided in question 11 a tax agent’s
4 Have you read and understood the Privacy notice at address?
question 22? No
No Yes ✔
Yes ✔
Eligibility for Medicare
Applicant’s details
13 What country was the applicant living in for 6 months or more
The applicant is the person who is applying for the Medicare
before arriving in Australia?
Entitlement Statement.

5 Does the applicant have a current or expired Medicare card?

No
14 How long was the applicant residing in that country?
(State total number of years and/or months in numerals,
Yes Provide the applicant’s Medicare card number and
reference number for example 10)
Applicant’s Medicare card number Years and/or months
 Ref no.
MS015.2008 2 of 4
15 Does the applicant hold current or expired health or medical Application 2 (if the applicant has lodged more than one
insurance in Belgium, Italy, the Netherlands, Norway or Slovenia Permanent residency application)
(for example European Health Insurance card, Tessera Sanitaria A Date application lodged
or AIRE registration)?
No / /
Yes Provide certified copies of the medical Provide a current letter or email from the
insurance documentation with this application. Department of Home Affairs that confirms the
date you lodged your application. You can get
16 Is the applicant from Finland, Malta or Norway? copies of these letters or emails from your
IMMIAccount at immi.homeaffairs.gov.au
No
www.

Yes Did the applicant enter Australia on a student visa? B Is the application for permanent residency, that is being
No Yes considered by the Department of Home Affairs, still
ongoing?
17 Has the applicant lodged an application for permanent residency No
(other than a parent visa) with the Department of Home Affairs,
this includes applications for Spouse Combined visas (subclass Yes Go to 18
820/801) and (subclass 309/100)? C Indicate if the application for permanent residency was:
No Go to 18 Tick one only
Yes Give details below Approved Date / / Go to 19
Application 1
Withdrawn Date / / Go to 19
A Date application lodged
Refused Date / / Go to D
/ /
Provide a current letter or email from the
Provide a current letter or email from the Department of Home Affairs that confirms your
Department of Home Affairs that confirms the application has been approved, withdrawn or
date you lodged your application. You can get refused. You can get copies of these letters or
copies of these letters or emails from your emails from your IMMIAccount at
IMMIAccount at immi.homeaffairs.gov.au
www.

immi.homeaffairs.gov.au
www.

B Is the application for permanent residency that is being D Has the applicant lodged an appeal against that
considered by the Department of Home Affairs, still decision?
ongoing? Provide a signed letter declaring
No
No that you have not lodged an appeal.
Yes Go to 18
Yes Provide evidence that an appeal
C Indicate if the application for permanent residency was: has been lodged with either the
Tick one only Administration Appeals Tribunal,
Federal Court, or High Court, or
Approved Date / / Go to 19 evidence that you have requested
/ / Ministerial Intervention.
Withdrawn Date Go to 19

Refused Date / / Go to D If the applicant has lodged more than 2 applications

for permanent residency, provide a separate sheet
Provide a current letter or email from the with details.
Department of Home Affairs that confirms your
application has been approved, withdrawn or 18 Has the applicant lodged an application for permanent residency
refused. You can get copies of these letters or with the Department of Home Affairs under parent category
emails from your IMMIAccount at (Aged parent or Contributory parent)?
immi.homeaffairs.gov.au
No
www.

D Has the applicant lodged an appeal against that decision? Yes Aged parent or Contributory parent
No Provide a signed letter declaring Date application lodged
that you have not lodged an appeal
/ /
Yes Provide evidence that an appeal
has been lodged with either the
Administration Appeals Tribunal,
Federal Court, or High Court, or
evidence that you have requested
Ministerial Intervention.

MS015.2008 3 of 4
Claiming period Privacy notice
19 • A separate application must be completed for each 22 You need to read this
financial year. Privacy and your personal information
• We are unable to certify any period after the date this The privacy and security of your personal information is
application is signed. important to us, and is protected by law. We need to collect this
• All periods must be in the same financial year. information so we can process and manage your applications
Which financial year is the applicant applying for? and payments, and provide services to you. We only share your
information with other parties where you have agreed, or where
1 July 20 ___
2 ___
0 to 30 June 20 ___
2 ___
1 the law allows or requires it. For more information, go to
Provide evidence of visa – endorsed in passport/email servicesaustralia.gov.au/privacy
www.

or letter from the Department of Home Affairs.

Declaration
20 Is the applicant leaving Australia permanently before the end of
the current financial year? 23 I declare that:
No • I have attached all relevant documents.
Yes Expected departure date / / • for the period(s) specified in question 19, I was a resident
of Australia for taxation purposes, and at the same time I
Checklist was not eligible for Medicare benefits, nor Medicare
benefits under a Reciprocal Health Care Agreement.
21 Before submitting an application make sure that: • the information I have provided in this form is complete and
A separate application is lodged for each financial year ✔ correct.
(if applicable) I understand that:
• information regarding this application is exchanged
All questions in the form have been completed ✔
between Medicare and the Australian Taxation Office.
The application form has been signed and dated ✔ • we may contact the Department of Home Affairs to obtain
by the applicant information relating to my immigration status (if required).
Which of the following documents are you providing with • giving false or misleading information is a serious offence.
this application?
A certified copy of the photo page ✔ This must be signed by the applicant
of the applicant’s passport Applicant’s signature
Visa evidence - endorsed in passport/email or letter from ✔ On completion, print and sign by hand.
the Department of Home Affairs -
A certified copy of evidence of a current or expired Date
Health Insurance card/medical insurance card or letter
showing expiry date / /
(if you answered Yes at question 15)
A letter or email from the Department of Home Affairs that Returning this form
confirms the date you lodged your application. You can get Return this form and any supporting documents:
copies of these letters or emails from your IMMIAccount • by email to: [email protected]
at immi.homeaffairs.gov.au
www.

There may be risks with sending personal information through

(if you answered Yes at question 17A) unsecured networks or email channels.
A copy of a current letter or email from the Department of All documents sent by email:
Home Affairs that confirms your application has been • must be in PDF format
approved, withdrawn or refused. You can get copies of
• must not be password protected, and
these letters or emails from your IMMIAccount at
• must not be larger than 10 megabytes
.

immi.homeaffairs.gov.au
www.

(if you answered No at question 17C) If you are sending applications for multiple applicants, a
separate email must be sent for each applicant.
Evidence that an appeal has been lodged with either the If the applicant has multiple applications for different financial
Administration Appeals Tribunal, Federal Court, or High Court, years, they can be sent in one email.
or evidence that you have requested Ministerial Intervention
(if you answered Yes at question 17D) • by post to:
Services Australia
Provide a signed letter declaring that you have not lodged Medicare Entitlement Statement Unit
an appeal GPO Box 9822
(if you answered No at question 17D) ADELAIDE SA 5001

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