Forms
Aged Care
- Application for the Oxygen and/or Enteral Feeding Supplement [PDF, 116k]
- Aged Care Funding Instrument Authorisation Form Annual aged care approved provider statement [PDF, 122k]
- Community Care Authorisation Form [PDF, 302k]
- Resident Classification Scale* [PDF, 151k]
- Resident Entry Record* [PDF, 643k]
- Request to Add/Change Banking Details Form* [PDF, 84k]
- Aged Care Funding Instrument Application for classification [PDF, 398k]
- Appointment of Nominee [PDF, 118k]
- Application for Classification (effective from 1 November 1998) [PDF, 125k]
- Authorisation Form - For use by Residential services participating in Aged Care online claiming [PDF, 179k]
- Aged Care Online Claiming Authorisation form - For use by residential services participating in Aged Care Online Claiming [PDF, 228k]
- Provider application for the electronic data of Department of Veteran’s Affairs claims for processing [PDF, 182k]
- Authorised signatory form for payments of subsidy under the Aged Care Act 1997 For use by services submitting manual forms [PDF, 165k]
- Annual Aged Care approved provider statement 2009-10 [PDF, 159k]
Australian Childhood Immunisation Register
- Immunisation History form and info [PDF, 80k]
- Immunisation Encounter form [PDF, 79k]
- Stationery Re-order form [PDF, 87k]
- Immunisation Encounter Header form [PDF, 73k]
- Immunisation exemption Medical Contraindication form [PDF, 138k]
- Conscientious Objection form [PDF, 131k]
- General practice Immunisation Incentives (GPII) GPII Practice Report (ACIR020A) Request form [PDF, 142k]
- Stationery Re-order form - QLD/NT [PDF, 39k]
- Application to Register as an Immunisation Provider [PDF, 87k] [PDF, 186Kb]
- Payment Account Details for Immunisation Providers form [PDF, 136k] [PDF, 185Kb]
- Agreement under Section 46E(2) of the Health Insurance Act 1973 [PDF, 145k] [PDF, 219Kb]
General
- Online claiming practice details [PDF, 105k]
- Broadband for Health - General Practice incentive claim form (1 July - 31 December 2007) Explanatory notes [PDF, 744k]
- Broadband for Health - incentive claim form for pharmacy (1 July - 31 December 2007) Explanatory notes [PDF, 738k]
- Notice of Judgement/Settlement [PDF, 208k]
- Statutory Declaration Notice of Judgement/Settlement [PDF, 222k]
- Request for a Notice of Past Benefits [PDF, 81k]
- Application for EFT payments for Medicare bulk bill and all DVA claims [PDF, 197k]
- Provider application for the electronic data transmission of Department of Veteran's Affairs claims for processing [PDF, 182k]
Medicare
- Online claiming for Medicare DVA provider agreement [PDF, 127k]
- Terms and conditions of approval of (proprietor) in respect of (hospital) [PDF, 55k]
- Terms and conditions of approval of (proprietor) in respect of (hospital) [PDF, 151k]
- Fax your Medicare Easyclaim order to 02 6230 477 [PDF, 151k]
- Online Claiming Banking Details form [PDF, 158k]
- Online Claiming Practice Details form [PDF, 105k]
- Update Online Claiming - Provider Details form [PDF, 105k]
- Health fund - electronic funds transfer (EFT) registration form [PDF, 81k]
- Billing Agent - Electronic transmission of Medicare claims agreement [PDF, 90k]
- Billing Agent - Electronic Funds Transfer (EFT) Registration form [PDF, 83k]
- Health fund - electronic transmission of Medicare claims agreement [PDF, 72k]
- Certification of Cleft Condition [PDF, 94k]
- Application for late lodgement of a claim for assigned Medicare Benefits [PDF, 99k]
- Request for Pay Group Link [PDF, 136k]
- Simplified Billing Assignment Claim form [PDF, 209k]
- Simplified Billing Adjustment claim form [PDF, 433k]
- Application form 90 day pay doctor cheques scheme [PDF, 63k]
- LSPN Location specific practice number registration form [PDF, 173k]
- Application for registering a Dental Specialty and info sheet [PDF, 222k]
- Application for an initial Medicare provider/registration number for a Dentist, Dental Specialist or Dental Prosthetist and info sheet [PDF, 241k]
- Application for recognition as a general practitioner Fellows of ACRRM [PDF, 130k]
- Vocational registration of a general practitioners application for certification of eligibility for vocational registration [PDF, 160k]
- Application for an initial Medicare provider number for a medical practitioner [PDF, 518k]
- Application for an additional location Medicare provider number for a medical practitioner [PDF, 303k]
- Application for an initial Medicare Australia provider/registration number for an allied health professional [PDF, 228k]
- Application for an additional location Medicare provider/registration number for an allied health professional [PDF, 303k]
- Application for Remote Area Exemption for 'R Type' Diagnostic Imaging Services for a Medical Practice [PDF, 120k]
- Common form of undertaking Participating Optometrists [PDF, 108k]
- Request to remove your name from Medicare Australia's list of recognised fellows [PDF, 130k]
- Request to remove your name from Medicare Australia's Vocational register of General Practitioners [PDF, 119k]
- Application for recognition as a Specialist or Consultant Physician and info sheet [PDF, 280k]
- Application for recognition as an Accredited Orthodontist [PDF, 147k]
- Application for an initial Medicare provider/registration number for an Optometrist [PDF, 223k]
- Schedule of optometrist on whose behalf optometrical services are provided by a non participating optometrist [PDF, 112k]
- After hours other Medical Practitioners (UMP's) Program Application Form [PDF, 90k]
- Application for recognition as a General Practitioner (fellows of RACGP) [PDF, 130k]
- Request to remove your name from Medicare Australia's List of recognised Australian College of Rural and Remote Medicine (ACRRM) Fellows [PDF, 128k]
- MRI Statutory Declaration and Instructions [PDF, 113k]
- Mental Health Nurse Incentives Payment claim [PDF, 160k]
- Mental Health Nurse Incentives Payment application [PDF, 196k]
- Mental Health Nurse Incentives Payment Establishment Payment application [PDF, 241k]
- Statutory Declaration for Positron Emission Tomography (PET) services [PDF, 121k]
- Run-off cover indemnity scheme (ROCS) - statutory declaration Medical Practice aged 65 years or over who has ceased private medical practice [PDF, 127k]
- Guidelines only Medical Indemnity High cost claim indemnity scheme (HCCS) payment application form [PDF, 242k]
- Guidelines only Medical Indemnity Run-off Cover Indemnity Scheme (ROCS) payment application form [PDF, 203k]
- Medical Indemnity Run-off Cover Indemnity Scheme (ROCS) payment application form [PDF, 106k]
- Run off cover indemnity scheme (ROCS) medical certificate [PDF, 59k]
- Run-off cover indemnity scheme (ROCS) statutory declarations [PDF, 127k]
- Medical Indemnity High Cost claim indemnity scheme (HCCS) payment application [PDF, 183k]
- Medical Indemnity United Medical Protection support payment Information and exemption application booklet for outstanding deferrals for members of United Medical Protection Ltd [PDF, 1,290k]
- Medical Indemnity United Medical Protection support payment Information and exemption booklet for outstanding deferrals of non-members of United Medical Protection Ltd [PDF, 1,300k]
- Medicare Easyclaim banking details for bulk bill claims [PDF, 131k]
- DB5 – Bulk Bill Assignment continuation form for pathology services only [PDF, 175Kb]
- DB1N – Bulk Bill claim form for Normal Services [PDF, 77Kb]
- DB1H – Bulk Bill claim form for Hospital Services [PDF, 86Kb]
- DB4E – Bulk Bill Assignment Form [PDF, 79Kb
- DB1N-AH – Bulk Bill claim form for Allied Health Professionals [PDF, 86Kb]
- DB2-AH – Bulk Bill claim form for Allied Health Professionals [PDF, 142Kb]
- DB2-OT – Bulk Bill claim form for Other Practitioners [PDF, 142Kb
- DB2-OP – Bulk Bill claim form for Optometrists [PDF, 115Kb]
- DB2-GP – Bulk Bill claim form for General Practitioners [PDF, 126Kb
- DB3 – Bulk Bill claim form for Pathologists [PDF, 122Kb]
- DB4 – Bulk Bill Assignment Form [PDF, 96Kb]
- DB1N-DP – Bulk Bill claim form for Dental Practitioners [PDF, 236k]
- DB4-DP – Bulk Bill Assignment form for Dental Practitioners [PDF, 286k]
National Bowel Cancer Screening Program
Pathology
- Application for approval of premises as an accredited pathology laboratory [PDF, 47k]
- Application for acceptance as an Approved Pathology Authority and Approved Pathology Undertaking [PDF, 180k]
- Application for acceptance as an approved pathology practitioner and Approved pathology practitioner undertaking [PDF, 81k]
- LSPN Registration form [PDF, 173k]
- Declaration Location specific Practice Number (LSPN) Equipment update form [PDF, 568k]
Pharmaceutical Benefits Scheme
- Application for Approval to Supply Pharmaceutical Benefits (by a registered medical practitioner) [PDF, 68k]
- Application for Approval for a Hospital Authority to Supply Pharmaceutical Benefits [PDF, 89k]
- Authority for Authorised Pharmacist(s) to Sign Claim Forms [PDF, 93k]
- PBS Medicine Export Declaration Form [PDF, 192k]
- Seemingly Valid Medicare Card Form [PDF, 67k]
- Rural Pharmacy Maintenance Allowance Certification Statement [PDF, 94k]
- Rural Pharmacy Maintenance Allowance Application Form [PDF, 92k]
- Application for Approval to Provide Home Medicines Review Services [PDF, 106k]
- Application for Temporary Approval to Supply Pharmaceutical Benefits by a Registered Medical Practitioner - Section 92 [PDF, 58k]
- PBS Online – Pharmacy Participation Agreement (Manual version) Online claiming for PBS program Pharmacy participation application and terms and conditions [PDF, 152k]
- Application for approval - expansion/contraction in size of an existing pharmacy [PDF, 124k]
- Application for approval - relocation of a pharmacy [PDF, 237k]
- Application for approval – change of ownership of a pharmacy (not involving a relocation) [PDF, 222k]
- Residential Medication Management Reviews(RMMR) - Change of details for Section 90 Pharmacy [PDF, 160k]
- Residential Medication Management reviews Contract registration change of details [PDF, 204k]
- Subfoveal choroidal neovascularisation PBS Authority application – initial treatment – supporting information form (operational from 1/4/07)
- Optometrist’s authority form [PDF, 72k]
- Pharmacy Connectivity Incentive Claim Form [PDF, 283k]
- Pharmacy Connectivity Incentive (PCI) Claim Form [PDF, 282k]
- Pharmacy Connectivity Incentive program UIN Application form [PDF, 116k]
- Application for approval by an optometrist to prescribe medications under the PBS [PDF, 122k]
- Software vendor assistance payment [PDF, 239k]
- Schedule of Pharmaceutical Benefits (order form) [PDF, 29k]
- Request for Pharmaceutical supplies for Aboriginal Health Services (AHS) [PDF, 89k]
- (Stationery order form) [PDF, 89k]
- Prescription Shopping Information service Registration form [PDF, 67k]
- Agreement for the Provision of collaborative and Pharmacists RMMR and associated quality use of medicines services [PDF, 48k]
- Deed of variation (MMRS) [PDF, 31k]
- Medication reviews in residential care services Quarterly Report [PDF, 102k]
- Residential medication Management Review (RMMR) multi-lodgement claim form [PDF, 49k]
- Application form residential Medication Management reviews (RMMR) [PDF, 212k]
- Prescription Shopping Information Service Access registration form [PDF, 330k]
- Medicine export declaration form [PDF, 192k]
- Order form non PBS sticky notes [PDF, 320k]
- Herceptin Program Information Sheet & Consent Form – Early Breast Cancer - PBS Authority Application [PDF, 356k]
- Application for approval - establish a new pharmacy [PDF, 219k]
- Application For Approval to Prescribe Medications under the PBS by a registered dental practitioner [PDF, 120k]
- Etanercept PBS Authority Application Supporting information form - Initial treatment of juveniles [PDF, 296k]
- Etanercept PBS Authority Application Supporting information form - Continuing treatment of juveniles [PDF, 277k]
- Etanercept PBS Authority Application Supporting information form - Initial treatment of adults (Juvenile onset prior to the age of 18 years) [PDF, 288k]
- Etanercept PBS Authority Application Supporting information form - Continuing treatment of adults (Juvenile onset prior to the age of 18 years) [PDF, 283k]
- Imatinib Mesylate (Glivec) Authority Application Supporting Information Form - Initial treatment in accelerated phase of treatment of myeloid leukaemia [PDF, 46k]
- IVF/GIFT Summary of Order Form [PDF, 145k]
- Bosentan Monohydrate (Tracleer) & Iloprost trometamol (Ventavis) - PBS authority application supporting information form for initial PBS subsidised treatment for hypertension [PDF, 86k]
- Biological Disease Modifying Anti-Rheumatic Drugs - PBS Authority Application Supporting Information Form – Initial PBS subsidised treatment of adults [PDF, 264k]
- Biological Disease Modifying Anti-Rheumatic Drugs - PBS Authority Application Supporting Information Form – Continuing PBS subsidised treatment of adults [PDF, 291k]
- Biological Disease Modifying Anti-Rheumatic Drug [PDF, 249k]
- Modafinil (Modavigil) PBS Authority Application – Initial PBS subsidised treatment
- Bosentan Monohydrate & Iloprost trometamol - PBS Authority Application supporting information form - change or recommencement [PDF, 82k]
- Tumour Necrosis Factor alpha antagonist – Continuing [PDF, 74k]
- Etanercept for psoriatic arthritis – PBS Authority Application – Supporting information form - Initial subsidised treatment of adults with severe arthritis [PDF, 261k]
- Etanercept for psoriatic arthritis – PBS Authority Application – Supporting information form - Continuing subsidised treatment of adults with severe arthritis [PDF, 314k]
- Imatinib Mesylate (Glivec) PBS Authority Application Supporting Information Form - Initial treatment in blast phase of myeloid leukaemia [PDF, 45k]
- Imatinib Mesylate (Glivec) PBS Authority Application Supporting Information Form - Initial treatment in chronic phase of myeloid leukaemia [PDF, 49k]
- PASI calculation and body diagram (for patient with severe chronic plaque psoriasis of the face, or a palm of a hand, or a sole of a foot) [PDF, 114k]
- PASI calculation and body diagram (for patient with severe chronic plaque psoriasis of whole body) [PDF, 85k]
- Chrohn’s disease – initial paediatric patients [PDF, 314k]
- Chrohn’s disease – grandfather paediatric patients [PDF, 309k]
- Chrohn’s disease – adult initial [PDF, 312k]
- Chrohn’s disease – continuation for all patients [PDF, 414k]
- Chrohn’s disease – grandfather adult [PDF, 304k]
Practice Incentives Program
- Practice Incentives Program change in authorised contact persons for correspondence and telephone enquiries [PDF, 59k]
- Procedural GP payment application form [PDF, 145k]
Prescription Shopping Information Service
Program Review Division
Public Key Infrastructure
- Application form for non-known Medicare Australia Healthcare Professional Individual certificate [PDF, 157k]
- Application form for non-known Medicare Australia Communities of interest Site Certificate [PDF, 232k]
- Medicare Australia Healthcare Professional Individual Certificate application form [PDF, 157k]
- Request for Revocation / suspension / reinstatement / renewal of Location & Individual certificates [PDF, 231k]
- Acceptable Referee Identification Form (Individual) [PDF, 100k]
- Acceptable Referee Identification Form (Site -Sole trader) [PDF, 115k]
- Acceptable Referee Identification Form (location - other) [PDF, 183k]
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