Forms
Medicare Australia has a range of forms for health professionals that can be downloaded to view, print, complete and return to us.
Follow these steps to find a form.
Step 1. Type all or part of the form name in the search field.
Step 2. Wait for the search results to display or select the button next to the search field.
Step 3. Select the form required.
If you are unsure of the name of the form, select Show all forms to view the full list of forms available.
Aged Care
- Application for the Oxygen and/or Enteral Feeding Supplement [PDF, 116k]
- 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]
- Annual Aged Care approved provider statement 2010-11 [PDF, 163k]
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 (IMMU11) [PDF, 138k]
- Immunisation exemption conscientious objection form (IMMU12) [PDF, 117k]
- General practice Immunisation Incentives (GPII) GPII Practice Report (ACIR020A) Request form (IMMU14) [PDF, 142k]
- Immunisation stationery order for QLD and NT
- Immunisation stationery order for NSW,VIC,SA,WA,TAS,ACT
- Application to Register as an Immunisation Provider [PDF, 186k]
- Payment Account Details for Immunisation Providers form [PDF, 135k]
- Agreement under Section 46E(2) of the Health Insurance Act 1973 [PDF, 219k]
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, 258k]
- Statutory Declaration Notice of Judgement/Settlement [PDF, 127k]
- Request for Medical History Statement [PDF, 192k]
- Provider registration for Electronic Funds Transfer payments form (2092_2) [PDF, 197k]
- Provider application for the electronic data transmission of Department of Veteran's Affairs claims for processing [PDF, 182k]
Healthcare Identifiers (HI) Service
- HI Service Authorised Employee details
- Online User Guide: Healthcare Identifiers (HI) Service – Authorised Employees
- Healthcare Identifier Service Application to Register a Healthcare Provider (2977)
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 Registration form [PDF, 193k]
- Application for registering a Dental Specialty and info sheet [PDF, 222k]
- Application for an initial Medicare provider number for a dentist or dental specialist [PDF, 149k]
- 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]
- 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]
- Positron Emission Tomography Statutory Declaration (1507) [PDF, 142k]
- 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 declaration - Deceased medical practitioner [PDF, 196k]
- Run off cover indemnity scheme (ROCS) statutory declaration - Medical practitioner aged 65 or over who has ceased either private or all remunerated medical practice [PDF, 165k]
- Run off cover indemnity scheme (ROCS) statutory declaration - Medical practitioner who has ceased medical practice because of maternity [PDF, 171k]
- Run off cover indemnity scheme (ROCS) statutory declaration - Medical practitioner who has ceased medical practice because of permanent disability [PDF, 216k]
- Run off cover indemnity scheme (ROCS) statutory declaration - Medical practitioner who has not engaged in either private or remunerated medical practice during the preceding 3 years [PDF, 207k]
- Run off cover indemnity scheme (ROCS) statutory declaration - Overseas medical practitioner [PDF, 199k]
- 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]
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]
- Registration for a Location Specific Practice Number form (0855) [PDF, 302k]
- Request to amend Location Specific Practice Number form (4509) [PDF, 260k]
Pharmaceutical Benefits Scheme
- Application for Approval to Supply Pharmaceutical Benefits (by a registered medical practitioner) [PDF, 68k]
- Applying for approval to supply Pharmaceutical Benefits at a particular premises (8013)[PDF, 237k]
- Application for Approval for a Hospital Authority to Supply Pharmaceutical Benefits [PDF, 89k]
- Notification of bank account details for a hospital authority (4236)[PDF, 119k]
- 'Authority for authorised pharmacist(s) to sign claim forms on behalf of Approved Pharmacist(s) (4042)[PDF, 141k]
- Authority for authorised pharmacist(s) to sign claim forms on behalf of Section 91 Permission holder (4113)[PDF, 128k]
- Authority for authorised person(s) to sign forms on behalf of a hospital authority (8944)[PDF, 143k]
- PBS Medicine Export Declaration Form [PDF, 192k]
- Seemingly Valid Medicare Card Form [PDF, 67k]
- Rural Pharmacy Maintenance Allowance Certification Statement (4149) [PDF, 169k]
- Rural Pharmacy Maintenance Allowance Application Form (4150) [PDF, 180k]
- 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]
- Online Claiming for Pharmaceutical Benefits Scheme Application and Terms and Conditions (4167) [PDF, 139k]
- Application for approval - expansion/contraction in size of an existing pharmacy [PDF, 124k]
- Application for approval Change of ownership of a pharmancy (not involving relocation) (4183)[PDF, 363k]
- 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]
- Medicine export declaration form [PDF, 192k]
- Herceptin Program Information Sheet & Consent Form — Early Breast Cancer - PBS Authority Application [PDF, 356k]
- 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, 134k]
- 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, 134k]
- 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 and General Practice Immunisation Incentive application form [PDF, 1.0Mb]
- Practice Incentives Program and General Practice Immunisation Incentive change of practice details form [PDF, 297Kb]
- Indigenous Health Incentive and PBS Co-Payment Measure Patient Registration and Consent [PDF, 206Kb]
- Indigenous Health Incentive and PBS Co-payment Measure Multiple Patient Registration and Consent [PDF, 268Kb]
- Change to authorised contact person(s) [PDF, 183Kb]
- After Hours Incentive application form [PDF, 166Kb]
- Cervical Screening, Asthma and Diabetes Incentives application form [PDF, 159Kb]
- eHealth Application Form [PDF, 144Kb]
- Individual GP Details form [PDF, 243Kb]
- Practice Incentives Program Indigenous Health Incentive and Pharmaceutical Benefits Scheme Co-payment Measure Patient withdrawal of consent form [PDF, 147Kb]
- Practice Incentives Program Indigenous Health Incentive and Pharmaceutical Benefits Scheme Co-payment Measure Practice application form [PDF, 161Kb]
- Practice Incentives Program Indigenous Health Incentive practice register authority (4910) [PDF, 120Kb]
- Practice Incentives Program and General Practice Immunisation Incentive Additional practice branch form [PDF, 156Kb]
- Practice Incentives Program and General Practice Immunisation Incentive Practice ownership details form [PDF, 168Kb]
- Practice Incentives Program and General Practice Immunisation Incentive Practice and practice branch closure form [PDF, 156Kb]
- Procedural GP payment application form [PDF, 168Kb]
- Service Incentive Payments (SIPs) banking details form [PDF, 165Kb]
- Teaching Incentive claim form [PDF, 362Kb]
Practice Nurse Incentive Program
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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