Request for Medicare claims
information (MS031)
When to use this form Details of person making request
Use this form to request Medicare claims information that is older
than 3 years for individuals and families. 1 Medicare card number
If you are requesting Medicare claims information for a person (other Ref no.
than children under 14 years of age) who cannot consent to the 2 Name
release of their own information (for example, they have a power of
attorney or they are deceased), in addition to completing this form, Dr Mr Mrs Miss Ms Other
please provide evidence of your authority to act on their behalf. Family name
Information that may be provided in response to your request will
include date of service, item claimed, item description, benefit
First given name
amount, payment method, relevant dates and provider names and
locations.
Second given name
Important information
Any changes to this form must be initialled by the relevant signatory.
3 Date of birth / /
Online services 4 Permanent address
You can view, download and print your Medicare claims information
for at least the last 3 years by accessing your Medicare Online
account through myGov.
Postcode
myGov is a secure way to access a range of government services
online with one username and password. You can create a myGov 5 Postal address (if different to above)
account at my.gov.au and link it to your Medicare online account.
www.
For more information Postcode
Go to servicesaustralia.gov.au or call 132 011 Monday to Friday,
6 Daytime phone number
www.
8:30 am to 5 pm, Australian Eastern Standard Time.
Call charges may apply. ( )
Mobile phone number
Filling in this form
You can complete this form on your computer, print and sign it.
Email
If you have a printed form:
• Use black or blue pen.
• Print in BLOCK LETTERS. We will send your personal information to the email address
• Where you see a box like this Go to 1 skip to the question
you provide above. Make sure the address is appropriate for
number shown. the receipt of your personal information.
Claims information request
7 Indicate the date range(s) for the claims information required.
Medicare claims history for the period
From / / to / /
(insert full date range for example, 01/05/2018 to 31/05/2019)
8 Are you requesting personal or family claims information?
Personal only Go to 14
Family only
Personal and family
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Family members aged 14 years and over Family member 2
9 Are you requesting information about other family members Dr Mr Mrs Miss Ms Other
aged 14 years or over? Family name
No Go to 10
Yes
First given name
Complete question 9 if information is required for other family
members aged 14 years and over.
Information requested for family members aged 14 years and Second given name
over, must be accompanied by their signature.
If the other family members are not listed on your Medicare
card they will need to submit a separate request. Date of birth
/ /
Family member 1
Would you like us to send your personal information to a
Dr Mr Mrs Miss Ms Other third party?
Family name No
Yes I authorise Services Australia to provide my
personal information requested in this form, to the
First given name following organisation or person:
Contact name
Second given name
Date of birth Organisation name
/ /
Would you like us to send your personal information to a
third party?
Postal address
No
Yes I authorise Services Australia to provide my
personal information requested in this form, to the
following organisation or person:
Contact name
Postcode
Family member 2 signature
Organisation name On completion, print and sign by hand.
-
Date
/ /
Postal address
If the information relates to more than 2 additional
family members aged 14 years and over, provide a
separate sheet with details.
Postcode
Family member 1 signature
On completion, print and sign by hand.
-
Date
/ /
MS031.2007 2 of 4
Requests for children under 14 years of age Child 2
Family name
A person with parental responsibility can generally get Medicare
or PBS information about a child where the child is under 14 years
of age and listed on the same Medicare card as the requesting First given name
person.
10 Are you requesting information for a child under 14 years of Second given name
age?
No Go to 14
Yes Other names child known by (if applicable)
11 Are you the child’s parent or guardian?
No You may not request this claims information / /
Date of birth
Yes If legal guardian, provide supporting documents Is the child a subject of Family Court orders?
Child 1 No
Family name Yes Provide a copy of the current court order.
Is the child listed on more than one Medicare card?
First given name No
Yes Provide details
Child’s other Medicare card number
Second given name
Ref no.
Child’s other address (if applicable)
Other names child known by (if applicable)
Date of birth / / Postcode
Is the child a subject of Family Court orders?
No Child 3
Yes Provide a copy of the current court order. Family name
Is the child listed on more than one Medicare card?
No First given name
Yes Provide details
Child’s other Medicare card number
Second given name
Ref no.
Child’s other address (if applicable)
Other names child known by (if applicable)
Postcode Date of birth / /
Is the child a subject of Family Court orders?
No
Yes Provide a copy of the current court order.
Is the child listed on more than one Medicare card?
No
Yes Provide details
Child’s other Medicare card number
Ref no.
Child’s other address (if applicable)
Postcode
If the information relates to more than 3 children
under 14 years of age, provide a separate sheet with
details.
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12 Would you like us to send your child’s/children’s personal Declaration
information to a third party?
No Go to 14 17 I declare that:
Yes • I have parental responsibility for each child under 14 years
of age for whom I have requested claims information.
13 I authorise Services Australia to provide my child’s/children’s
personal information requested in this form, to the following • the information I have provided in this form is complete and
organisation or person: correct.
Contact name I understand that:
• giving false or misleading information is a serious offence.
Applicant’s signature
Organisation name
On completion, print and sign by hand.
-
Postal address
Date
/ / Reset form Print form
Postcode Returning this form
Check that all required questions are answered and that the form
Authorisation is signed and dated.
If you have indicated that the information requested in this form
14 Would you like us to send your personal information to a third should be provided to a third party, please return this completed
party?
form to that third party.
No Go to 16
The third party is responsible for returning this completed form
Yes
and any supporting documents:
15 I authorise Services Australia to provide my personal information • by email to:
requested in this form, to the following organisation or person:
[email protected] Contact name There may be risks with sending personal information through
unsecured networks or email channels.
• by visiting one of our service centres.
Organisation name
Postal address
Postcode
Privacy notice
16 The privacy and security of your personal information is
important to us, and is protected by law. We need to 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
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