Medicare Australia Claim Forms by flw11971


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									       Application for late lodgement of a claim for assigned Medicare benefits
Important information                                                Certification
Subsection 20B(2)(b) of the Health Insurance Act 1973
provides that a claim for assigned Medicare benefits must            5 I apply for approval to late lodge the attached claim for
be lodged with Medicare Australia within two years of the                assigned Medicare benefits.
date of a professional service (effective as of 1 April 2007).
                                                                         Claim number
You may apply to extend the two year time limit for lodging
a claim for an assigned Medicare benefit.                            6 Reasons for late lodgement
Medicare Australia will assess your application and decide                     If insufficient space, attach a separate statement
whether to allow you more than two years to lodge your                         with reasons for late lodgement.
claim. Medicare Australia will consider all matters relevant
to your application, including any hardship that might be
caused to you if this application is not approved.

If you need assistance completing this form, call
Medicare Australia on 132 150 (call charges may apply).

Send the completed and signed form, together with the
completed Medicare assignment forms and a completed
Medicare claims header form to:
Medicare Australia
GPO Box 9822
in your capital city
or fax to:
NSW 02 9895 3437                SA 08 8274 9408
VIC 03 9605 7983                TAS 03 6215 5322
QLD 07 3004 5281                WA 08 9214 8370

Tick where applicable ✓

Provider details

1 Dr      Mr   Mrs          Miss      Ms       Other
   Family name

   First given name

2 Mailing address

3 Provider number

4 Location ID/Minor ID

                                                                                                       Continued over the page

                                                           Page 1 of 2                                               0989.16.02.09
7 I declare that:
   •	 the information supplied in this application is true
      and correct
   •	 giving false or misleading information is a serious
   Print full name in BLOCK LETTERS

   Your signature

        /       /

Privacy note
The information provided on this form will be used to
process an application for late lodgement of Medicare
and/or Dental benefits payable for services rendered. The
collection of this information is authorised by the Health
Insurance Act 1973 and/or Dental Benefits Act 2008. This
information may be disclosed to the Department of Health
and Ageing, Centrelink, other relevant agencies, to a person
in the medical and/or dental practice associated with the
claim or where required or authorised by law.

Office use only
Approval granted for lodgement of claim number

                                on      /    /

Time allowed for late lodgement

Approval not granted
Delegate of the Chief Executive Officer of Medicare
Australia on behalf of the Minister for Health and Ageing

    /       /

                                                             Page 2 of 2   0989.16.02.09

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