PATIENT AGREEMENT FOR ASSIGNMENT OF MEDICARE BENEFIT Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.PATIENT DETAILSFull name *DOB *Date of appointment *Which Doctor is your tele-health consultation with? *Dr Adelaide BoylanDr Sarah HillDr Giovanni MelinoDr Jesser BeumerDr George BalalisTo authorise the bulk billing of your appointment by the doctor you are seeing. If you (the patient) agree to the assignment of the Medicare benefit directly to the health professional (bulk bill), complete this form with the following words: I agree to the assignment of the Medicare benefit directly to the health professional *YesNoFULL Name is required please *Privacy Note *Your personal information is protected by law, including the Privacy Act 1988, and is collected by Services Australia for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the agency, or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations). You can get more information about the way in which the agency will manage your personal information, including our privacy policy.Privacy Policy Signature * Clear Signature Submit
Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.PATIENT DETAILSFull name *DOB *Date of appointment *Which Doctor is your tele-health consultation with? *Dr Adelaide BoylanDr Sarah HillDr Giovanni MelinoDr Jesser BeumerDr George BalalisTo authorise the bulk billing of your appointment by the doctor you are seeing. If you (the patient) agree to the assignment of the Medicare benefit directly to the health professional (bulk bill), complete this form with the following words: I agree to the assignment of the Medicare benefit directly to the health professional *YesNoFULL Name is required please *Privacy Note *Your personal information is protected by law, including the Privacy Act 1988, and is collected by Services Australia for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the agency, or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations). You can get more information about the way in which the agency will manage your personal information, including our privacy policy.Privacy Policy Signature * Clear Signature Submit
