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Medicare enrolment form (MS004) MS004.2205 1 of 13 When to use this form Use this form to enrol in Medicare for the first time, re-enrol in Medicare or enrol your newborn child in Medicare. This form allows you to enrol up to 5 people in Medicare. If you have more than 5 people to enrol, you will need to complete an additional Medicare enrolment form. Medicare Safety Net The Medicare Safety Net helps people with high out of pocket medical costs for out of hospital services. It is available to individuals and families. Individuals are automatically registered but couples and families must register. If you are registered as a family, we combine your medical costs so you are more likely to reach the threshold amounts sooner. For Medicare Safety Net purposes, a family is any of these: • a married couple not separated, with or without dependants • a couple in a de facto relationship, with or without dependants • a single person with dependants. A dependant is someone who the family supports financially and is a child under 16 years or a full time student between 16 and 25 years. For more information about registering for the Medicare Safety Net, go to www.servicesaustralia.gov.au/safetynet Lifetime Health Cover Lifetime Health Cover (LHC) is designed to encourage people to take out private hospital cover earlier in life. If someone does not take out and maintain private hospital cover from the year they turn 31, they will pay a 2% LHC loading on top of their premium for every year they are aged over 30. Hospital cover must be purchased by 1 July following a person’s 31st birthday to avoid paying a LHC loading. Newly arrived migrants and applicants for permanent residency aged 31 or over will not have to pay a LHC loading if private hospital cover is purchased within 12 months of being enrolled in Medicare. If this applies to you, you will need to obtain a LHC letter from Medicare as proof of your Medicare registration and give this to your private health insurer to demonstrate your exemption from the loading. For more information, go to www.privatehealth.gov.au My Health Record A My Health Record is an online summary of an individual’s health information. Individuals listed on this form can get a My Health Record when enrolled in Medicare. Questions relating to My Health Record are outlined in Part C (Enrolling a newborn child) and Part D (My Health Record) of this form. For more information about My Health Record, go to www.myhealthrecord.gov.au Aboriginal and Torres Strait Islander Australian The Aboriginal and Torres Strait Islander Australian question is voluntary and will not affect your application. If you do answer, the information will help us to continue to improve services to Aboriginal and Torres Strait Islander Australians. You can have this information removed from Medicare records at any time by calling the Aboriginal and Torres Strait Islander Access Line on 1800 556 955 or by visiting one of our service centres. Call charges may apply. Australian South Sea Islander Australian South Sea Islanders are the descendants of Pacific Islander labourers brought from the Western Pacific in the 19th Century. The Australian South Sea Islander descent questions are also voluntary. For more information For more information about Medicare enrolments, go to www.servicesaustralia.gov.au/enrolmedicare or call 132 011 Monday to Friday, 8:30 am to 5 pm, Australian Eastern Standard Time. To speak to us in your language call 131 450. Call charges may apply. Filling in this form You can complete this form on your computer using Adobe Acrobat Reader, and some browsers, or you can print it. If you have a printed form: • Use black or blue pen. • Print in BLOCK LETTERS. • Where you see a box like this Go to 1 skip to the question number shown. Medicare enrolment form (MS004) MS004.2205 2 of 13 Type of enrolment 1 What are you using this form for? Enrolling in Medicare for the first time (for persons aged 12 months and older and newborn children born overseas) Go to Part A Question 2 Re-enrolling in Medicare or extending Medicare eligibility (for example, resident returning to Australia, Interim or Reciprocal Medicare card holders) Go to Part A Question 3 Enrolling a newborn child (for children aged up to their 1st birthday who are born in Australia) Go to Part C Registering for a My Health Record The My Health Record questions must be completed for persons listed in Part A and Part B of this form. Note: If you are using this form to enrol a newborn child, you do not need to complete Part D. Go to Part D Part A – Enrolling in Medicare for the first time, re-enrolling in Medicare or extending Medicare eligibility 2 Enrolling in Medicare for the first time Documents required for each person: Australian citizen • Australian passport, or • birth certificate and either a current Australian driver licence, student card or proof of age card, and • 2 residency documents (see page 3). If you are enrolling as a family, 2 residency documents are required per family. For more information, go to www.servicesaustralia.gov.au/enrolmedicare Child born overseas to an Australian citizen For each child provide: • a birth certificate and Australian passport, or • a birth certificate, foreign passport, and Australian citizenship certificate. If you have been living overseas more than 5 years, you will also need to provide: • 2 residency documents (see page 3), or • a statutory declaration saying the family has returned to live in Australia. For more information, go to www.servicesaustralia.gov.au/enrolmedicare New Zealand citizen residing in Australia • a New Zealand passport and • 2 residency documents (see page 3). If you are enrolling as a family, 2 residency documents are required per family. For more information, go to www.servicesaustralia.gov.au/enrolmedicare Permanent resident (but not an Australian citizen) • a current passport or Immicard, and • proof of permanent residency from the Department of Home Affairs. Have applied for permanent residency/permanent protection visa • a current passport or Immicard, and • proof that an application for permanent residency has been lodged with the Department of Home Affairs (and information about the category of visa that has been applied for), and • a valid visa. If your visa does not allow you to work in Australia, you must prove you have a relationship with your: parent, spouse, de facto, or your child who is an Australian citizen, permanent resident or a New Zealand citizen living in Australia. For more information, go to www.servicesaustralia.gov.au/enrolmedicare Visitor from a country that has a Reciprocal Health Care Agreement with Australia • a current passport or travel document, • a current visa, • evidence of all Australian arrival and departure dates, • proof of overseas health insurance, • documents to prove your country of residence. Not all of the above information is required for each visitor to Australia. For more information, go to www.servicesaustralia.gov.au/rhca Other visa holders – covered by Ministerial Order • current passport or travel document or ImmiCard, and • proof of a valid visa from the Department of Home Affairs. MCA0MS004 2205 MS004.2205 3 of 13 3 Re-enrolling in Medicare or extending Medicare eligibility Documents required: Returning to reside in Australia permanently For example: • Australian citizens returning to live in Australia after more than 5 years • New Zealand citizens or permanent residents returning to live in Australia after 12 months or more. For each person provide: • a current passport, and • 2 residency documents (see page 3). If you are enrolling as a family, 2 residency documents are required per family. Extend my Medicare eligibility This is applicable to Interim Medicare card or Reciprocal Medicare card holders who wish to apply for an extension. For each person provide: • a current passport or ImmiCard, and • a current visa, and • evidence from the Department of Home Affairs that you have applied for another visa (if relevant). If you have lodged an appeal against a refused visa decision, you need to provide a letter or email from the Administrative Appeals Tribunal. Residency documents Residency documents can be made up of 2 documents from Australia or 1 document from Australia and 1 from where the person last lived. Documents must be dated within the last 6 months. Documents from another country • sale of property (sale agreement) • cessation of lease agreement for rental property • termination of employment (acceptance of resignation by employer) • transit document for household goods and/or furniture • closure of bank accounts • cancellation of health, property or contents insurance. Documents from Australia • purchase of property agreement and gas or electricity accounts in same name • lease agreement for rental of property and gas or electricity accounts in same name • evidence of employment • evidence of children at school or university • private health insurance in Australia • opening of bank accounts • property or contents insurance. Medicare contact person You will be the nominated contact person who we will send the Medicare card(s) and general information to on behalf of everyone listed on the Medicare card(s). Your details 4 Mr Mrs Miss Ms Other Family name First given name Second given name 5 Have you ever used or been known by another name? No Yes Give details of your previous name 6 Date of birth (DD MM YYYY) 7 Gender Male Female 8 Postal address Postcode 9 Contact phone number (including area code) 10 If you: • are enrolling in Medicare for the first time Go to 11 • are re-enrolling in Medicare or wanting to extend your Medicare eligibility Your previous Medicare card number (if known) Ref no. Go to 11 • only want to enrol a dependant in Medicare (for example, a newborn child born overseas or a child aged 12 months or over). Your current Medicare card number Ref no. Go to 19 MS004.2205 4 of 13 11 Are you of Aboriginal or Torres Strait Islander Australian descent? If you are of both Aboriginal and Torres Strait Islander Australian descent, tick both ‘Yes’ boxes. No Yes – Aboriginal Australian Yes – Torres Strait Islander Australian 12 Are you of Australian South Sea Islander descent? No Yes 13 Have you previously lived overseas? No Go to 18 Yes Go to next question 14 Previous country of residence before arriving in Australia 15 How long were you residing in that country? (state the total number of years and/or months) years months 16 Date of arrival in Australia (DD MM YYYY) 17 Do you have plans to reside in Australia permanently? No Planned date of departure (if known) (DD MM YYYY) Yes 18 Do you require a Lifetime Health Cover letter? (For more information, see page 1 of this form) No Yes Bank account details 19 All payments are made through Electronic Funds Transfer (EFT). Payments cannot be made via EFT if the nominated account has restrictions on EFT deposits. Payments cannot be made to an account used exclusively for funding from the National Disability Insurance Scheme. We cannot record bank account details for children under 14 years of age. Name of bank, building society or credit union (Australian financial institutions only) Branch number (BSB) Account number (this may not be the card number) Account held in the name(s) of Privacy notice 20 The privacy and security of your personal information is important to us, and is protected by law. We collect this information so we can process and manage your applications and payments, and provide services to you. We only share your information with other parties where you have agreed, or where the law allows or requires it. For more information, go to www.servicesaustralia.gov.au/privacy Declaration 21 I declare that: • I have read and understood the Privacy notice. • I am aware of my legal obligation to provide true and accurate information. • the information I have provided in this form is complete and correct. I consent to: • the agency validating identity documents I provide with the issuing agency. I authorise for: • payments to be made into the bank account I nominated in this form. I understand that: • identification documents provided to Services Australia will be checked with the issuing agency to confirm validity. The documents are subject to agency compliance and