Application to copy or transfer from one Medicare card to another Instructions

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This form contains 183 fields organized into 47 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Aboriginal or Torres Strait Islander Descent (Person 1)
No Checkbox
Check this box if the person is not of Aboriginal or Torres Strait Islander Australian descent.
Yes - Aboriginal Australian Checkbox
Check this box if the person is of Aboriginal Australian descent.
Yes - Torres Strait Islander Australian Checkbox
Check this box if the person is of Torres Strait Islander Australian descent.
Aboriginal or Torres Strait Islander Descent (Person 2)
No Checkbox
Check this box if Person 2 is not of Aboriginal or Torres Strait Islander Australian descent. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Yes - Aboriginal Australian Checkbox
Check this box if Person 2 is of Aboriginal Australian descent. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Yes - Torres Strait Islander Australian Checkbox
Check this box if Person 2 is of Torres Strait Islander Australian descent. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Aboriginal or Torres Strait Islander Descent Status
Aboriginal or Torres Strait Islander Descent No Text
Please indicate your response regarding Aboriginal or Torres Strait Islander Australian descent.
No Checkbox
Check this box if the person is not of Aboriginal or Torres Strait Islander Australian descent.
Yes - Aboriginal Australian Checkbox
Check this box if the person is of Aboriginal Australian descent.
Yes - Torres Strait Islander Australian Checkbox
Check this box if the person is of Torres Strait Islander Australian descent.
Aboriginal or Torres Strait Islander Descent - No Text
Indicate if you are not of Aboriginal or Torres Strait Islander Australian descent.
No Checkbox
Check this box if you are not of Aboriginal or Torres Strait Islander Australian descent.
Yes - Aboriginal Australian Checkbox
Check this box if you are of Aboriginal Australian descent.
Yes - Torres Strait Islander Australian Checkbox
Check this box if you are of Torres Strait Islander Australian descent.
Australian South Sea Islander Descent (Person 1)
No Checkbox
Check this box if you are not of Australian South Sea Islander descent.
Yes Checkbox
Check this box if you are of Australian South Sea Islander descent.
Australian South Sea Islander Descent (Person 2)
No Checkbox
Check this box if the person is not of Australian South Sea Islander descent. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Yes Checkbox
Check this box if the person is of Australian South Sea Islander descent. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Australian South Sea Islander Descent Status
No Checkbox
Check this box if you are not of Australian South Sea Islander descent.
Yes Checkbox
Check this box if you are of Australian South Sea Islander descent.
No Checkbox
Check this box if you are NOT of Australian South Sea Islander descent.
Yes Checkbox
Check this box if you ARE of Australian South Sea Islander descent.
Bank Account Details
Bank Name Text
Enter the full name of the bank, building society, or credit union where the account is held.
BSB Text
Enter the Branch State Bank (BSB) number for the account.
Max length: 6 characters
Account Number Text
Enter the bank account number for the nominated account.
Account Holder Name Text
Enter the full name(s) of the individual(s) or entity in whose name the bank account is held.
Card Action Request
Transfer to new card with Person 1 Checkbox
Check this box if you would like to transfer to a new card with Person 1.
Copy to new card with Person 1 Checkbox
Check this box if you would like to copy to a new card with Person 1.
Transfer to a new card Checkbox
Check this box if you would like to transfer to a new card.
Copy to a new card Checkbox
Check this box if you would like to copy to a new card.
Transfer to an existing card Checkbox
Check this box if you would like to transfer to an existing card.
Copy to an existing card Checkbox
Check this box if you would like to copy to an existing card.
Child Age and Relationship Information
No Checkbox
Check this box if none of persons 1, 2, or 3 are younger than 15 years old.
Yes Checkbox
Check this box if any of persons 1, 2, or 3 are younger than 15 years old.
Relationship to Child Text
Provide your relationship to the child or children who are younger than 15 years old, for example, grandparent. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Contact Details
Contact Phone Number Text
Please enter your contact phone number, including the area code.
Max length: 10 characters
Email Address Text
Please provide your email address.
Contact Phone Number (Person 1)
Contact Phone Number (Person 1) Text
Enter the contact phone number for Person 1, including the area code.
Max length: 10 characters
Date of Birth of Person 3
Day of Birth Text
Please enter the day of birth for Person 3.
Max length: 2 characters
Month of Birth Text
Please enter the month of birth for Person 3.
Max length: 2 characters
Year of Birth Text
Please enter the year of birth for Person 3.
Max length: 4 characters
Date of Birth on Existing Medicare Card
Day of Birth Text
Enter the day of the birth date on the existing Medicare card. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Month of Birth Text
Enter the month of the birth date on the existing Medicare card. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Year of Birth Text
Enter the year of the birth date on the existing Medicare card. Fill only if 'Yes' is 'Yes'.
Max length: 4 characters
Depends on: Yes
Declaration (Person 2)
Person 2 Full Name Text
Enter the full name of Person 2 as part of their declaration. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
I have read, understood, and agree to the above Checkbox
Check this box to confirm that you have read, understood, and agree to the declarations, consents, and understandings outlined above regarding Person 2's information. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Declaration Day Date
Enter the day of the declaration date in DD format. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Declaration Month Date
Enter the month of the declaration date in MM format. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Declaration Year Date
Enter the year of the declaration date in YYYY format. Fill only if 'Yes' is 'Yes'.
Max length: 4 characters
Depends on: Yes
Declaration of Parent, Guardian, or Primary Carer
Full Name of Parent, Guardian or Primary Carer Text
Enter the full name of the parent, guardian, or primary carer making the declaration.
I have read, understood and agree to the above. Checkbox
Check this box to confirm that you, as the parent, guardian, or primary carer, have read, understood, and agree to the information presented in the declaration.
Declaration Date Day Text
Enter the day of the declaration date in DD format.
Max length: 2 characters
Declaration Date Month Text
Enter the month of the declaration date in MM format.
Max length: 2 characters
Declaration Date Year Text
Enter the year of the declaration date in YYYY format.
Max length: 4 characters
Declaration of Person 1
Person 1 Full Name Text
Please enter the full name of Person 1.
I have read, understood and agree to the above Checkbox
Check this box if you have read, understood, and agree to the terms and conditions outlined in the Declaration of Person 1.
Declaration Date Day Text
Please enter the day (DD) of the declaration date.
Max length: 2 characters
Declaration Date Month Text
Please enter the month (MM) of the declaration date.
Max length: 2 characters
Declaration Date Year Text
Please enter the year (YYYY) of the declaration date.
Max length: 4 characters
Declaration of Person 3
Declarant Full Name Text
Provide the full name of the person making this declaration.
I have read, understood, and agree to the above Checkbox
Check this box to confirm that you have read, understood, and agree to all the statements made in the 'Declaration of person 3' section, including the declarations, consent, and understandings.
Declaration Day Date
Enter the day of the declaration date.
Max length: 2 characters
Declaration Month Date
Enter the month of the declaration date.
Max length: 2 characters
Declaration Year Date
Enter the year of the declaration date.
Max length: 4 characters
Declaration of Person on Medicare Card
Declarant's Full Name Text
Please enter the full name of the person making this declaration, as they are on the existing Medicare card.
I have read, understood and agree to the above. Checkbox
Check this box to confirm that you have read, understood, and agree to the terms of the declaration for the person on the existing Medicare card.
Declaration Date Day Text
Please enter the day (DD) of the date this declaration is signed.
Max length: 2 characters
Declaration Date Month Text
Please enter the month (MM) of the date this declaration is signed.
Max length: 2 characters
Declaration Date Year Text
Please enter the year (YYYY) of the date this declaration is signed.
Max length: 4 characters
Duplicate Medicare Card Request
No Checkbox
Check this box if you do not need a duplicate Medicare card.
Yes Checkbox
Check this box if you need a duplicate Medicare card.
Email (Person 1)
Email Address Text
Provide the email address for Person 1.
Existing Medicare Card Number
Medicare Card Number Segment 1 Text
Enter the first segment of the existing Medicare card number. Fill only if 'Yes' is 'Yes'.
Max length: 4 characters
Depends on: Yes
Medicare Card Number Segment 2 Text
Enter the second segment of the existing Medicare card number. Fill only if 'Yes' is 'Yes'.
Max length: 5 characters
Depends on: Yes
Medicare Card Number Segment 3 Text
Enter the third segment of the existing Medicare card number. Fill only if 'Yes' is 'Yes'.
Max length: 1 characters
Depends on: Yes
Medicare Card Reference Number Text
Enter the reference number of the existing Medicare card. Fill only if 'Yes' is 'Yes'.
Max length: 1 characters
Depends on: Yes
Existing Medicare Card Transfer Status
No Checkbox
Check this box if persons 1, 2, or 3 are not copying or transferring to an existing Medicare card, and you should go to question 40.
Yes Checkbox
Check this box if persons 1, 2, or 3 are copying or transferring to an existing Medicare card, and you should complete questions 30 to 39.
First Parent or Guardian Declaration
Parent/Guardian 1 Full Name Text
Enter the full name of the first parent or guardian making this declaration. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
I have read, understood and agree to the above. Checkbox
Check this box to confirm that you have read, understood, and agree to the terms mentioned in the parent or guardian declaration. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Parent/Guardian 1 Declaration Day Text
Enter the day of the date the first parent or guardian signed this declaration. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Parent/Guardian 1 Declaration Month Text
Enter the month of the date the first parent or guardian signed this declaration. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Parent/Guardian 1 Declaration Year Number
Enter the year of the date the first parent or guardian signed this declaration. Fill only if 'Yes' is 'Yes'.
Max length: 4 characters
Depends on: Yes
Gender of Person 3
Male Checkbox
Check this box if the gender of Person 3 is male.
Female Checkbox
Check this box if the gender of Person 3 is female.
Non-binary Checkbox
Check this box if the gender of Person 3 is non-binary.
Gender on Existing Medicare Card
Male Checkbox
Check this box if the gender of the person on the existing Medicare card is male. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Female Checkbox
Check this box if the gender of the person on the existing Medicare card is female. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Non-binary Checkbox
Check this box if the gender of the person on the existing Medicare card is non-binary. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
General
Button
Medicare Card Details (Person 2)
Medicare Card Number Segment 1 Number
Enter the first segment of the Medicare card number for Person 2. Fill only if 'Yes' is 'Yes'.
Max length: 4 characters
Depends on: Yes
Medicare Card Number Segment 2 Number
Enter the second segment of the Medicare card number for Person 2. Fill only if 'Yes' is 'Yes'.
Max length: 5 characters
Depends on: Yes
Medicare Card Number Segment 3 Number
Enter the third segment of the Medicare card number for Person 2. Fill only if 'Yes' is 'Yes'.
Max length: 1 characters
Depends on: Yes
Medicare Card Reference Number Text
Enter the individual reference number found on the Medicare card for Person 2. Fill only if 'Yes' is 'Yes'.
Max length: 1 characters
Depends on: Yes
Medicare Card Number Person 3
Medicare Card Number Part 1 Text
Please enter the first four digits of the Medicare card number for person 3.
Max length: 4 characters
Medicare Card Number Part 2 Text
Please enter the middle three digits of the Medicare card number for person 3.
Max length: 5 characters
Medicare Card Number Part 3 Text
Please enter the last three digits of the Medicare card number for person 3.
Max length: 1 characters
Medicare Card Reference Number Text
Please enter the single-digit reference number from the Medicare card for person 3.
Max length: 1 characters
Name of Person 3
Dr Checkbox
Check this box if the person's title is Doctor.
Mr Checkbox
Check this box if the person's title is Mr.
Mrs Checkbox
Check this box if the person's title is Mrs.
Miss Checkbox
Check this box if the person's title is Miss.
Ms Checkbox
Check this box if the person's title is Ms.
Mx Checkbox
Check this box if the person's title is Mx.
Other Title Text
Provide your preferred title if it is not listed in the standard options. Fill only if 'Mx' is 'Yes'.
Depends on: Mx
Family Name Text
Enter the family name of Person 3.
First Given Name Text
Enter the first given name of Person 3.
Second Given Name Text
Enter the second given name of Person 3.
Name on Existing Medicare Card
Mr Checkbox
Check this box if the person's title is Mr. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Mrs Checkbox
Check this box if the person's title is Mrs. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Miss Checkbox
Check this box if the person's title is Miss. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Ms Checkbox
Check this box if the person's title is Ms. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Mx Checkbox
Check this box if the person's title is Mx. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Other Title Text
Please enter your custom title if it is not listed among the provided options, as it appears on the existing Medicare card. Fill only if 'Mx' is 'Yes'.
Depends on: Mx
Family Name Text
Please enter the family name as it appears on the existing Medicare card. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
First Given Name Text
Please enter the first given name as it appears on the existing Medicare card. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Second Given Name Text
Please enter the second given name as it appears on the existing Medicare card. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Person 1 Action Request
Transfer to a new card Checkbox
Check this box if Person 1 wishes to transfer their details to a new card.
Copy to a new card Checkbox
Check this box if Person 1 wishes to copy their details to a new card.
Transfer to an existing card Checkbox
Check this box if Person 1 wishes to transfer their details to an existing card.
Copy to an existing card Checkbox
Check this box if Person 1 wishes to copy their details to an existing card.
Person 1 Date of Birth
Day of Birth Text
Enter the day of Person 1's birth.
Max length: 2 characters
Month of Birth Text
Enter the month of Person 1's birth.
Max length: 2 characters
Year of Birth Text
Enter the year of Person 1's birth.
Max length: 4 characters
Person 1 Gender
Male Checkbox
Select this box if Person 1 identifies as male.
Female Checkbox
Select this box if Person 1 identifies as female.
Non-binary Checkbox
Select this box if Person 1 identifies as non-binary.
Person 1 Medicare Card Details
Medicare Card Number Part 1 Text
Please enter the first part of Person 1's Medicare card number.
Max length: 4 characters
Medicare Card Number Part 2 Text
Please enter the second part of Person 1's Medicare card number.
Max length: 5 characters
Medicare Card Number Part 3 Text
Please enter the third part of Person 1's Medicare card number.
Max length: 1 characters
Medicare Card Reference Number Text
Please enter the reference number for Person 1's Medicare card.
Max length: 1 characters
Person 1 Name
Family Name Text
Please enter the family name for Person 1.
First Given Name Text
Please enter the first given name for Person 1.
Second Given Name Text
Please enter the second given name for Person 1.
Person 1 Previous Name
No Checkbox
Check this box if Person 1 has never used or been known by another name.
Yes Checkbox
Check this box if Person 1 has previously used or been known by another name.
Previous Name Text
Provide the full previous name of Person 1. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Person 1 Title
Mr Checkbox
Check this box if Person 1's title is Mr.
Mrs Checkbox
Check this box if Person 1's title is Mrs.
Miss Checkbox
Check this box if Person 1's title is Miss.
Ms Checkbox
Check this box if Person 1's title is Ms.
Mx Checkbox
Check this box if Person 1's title is Mx.
Other Title Text
Please enter the title for Person 1 if it is not Mr, Mrs, Miss, Ms, or Mx.
Person 2 Copy/Transfer Options
Transfer to a new card with person 1 Checkbox
Check this box if Person 2 wishes to transfer to a new Medicare card shared with Person 1. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Copy to a new card with person 1 Checkbox
Check this box if Person 2 wishes to be copied onto a new Medicare card shared with Person 1. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Transfer to a new card Checkbox
Check this box if Person 2 wishes to transfer to a new Medicare card. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Copy to a new card Checkbox
Check this box if Person 2 wishes to be copied onto a new Medicare card. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Transfer to an existing card Checkbox
Check this box if Person 2 wishes to transfer to an existing Medicare card. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Copy to an existing card Checkbox
Check this box if Person 2 wishes to be copied onto an existing Medicare card. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Person 2 Date of Birth
Person 2 Day of Birth Text
Please provide the day of birth for Person 2. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Person 2 Month of Birth Text
Please provide the month of birth for Person 2. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Person 2 Year of Birth Text
Please provide the year of birth for Person 2. Fill only if 'Yes' is 'Yes'.
Max length: 4 characters
Depends on: Yes
Person 2 Full Name
Mr Checkbox
Check this box if Person 2's title is Mr. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Mrs Checkbox
Check this box if Person 2's title is Mrs. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Miss Checkbox
Check this box if Person 2's title is Miss. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Ms Checkbox
Check this box if Person 2's title is Ms. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Mx Checkbox
Check this box if Person 2's title is Mx. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Text
Depends on: Yes
Family Name Text
Please enter the family name of Person 2. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
First Given Name Text
Please enter the first given name of Person 2. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Second Given Name Text
Please enter the second given name of Person 2. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Person 2 Gender
Male Checkbox
Check this box if the person identifies as male. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Female Checkbox
Check this box if the person identifies as female. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Non-binary Checkbox
Check this box if the person identifies as non-binary. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Postal Address
Address Line 1 Text
Please provide the first line of the postal address.
Address Line 2 Text
Please provide the second line of the postal address.
Suburb/City Text
Please provide the suburb or city for the postal address.
Postcode Text
Please provide the postcode for the postal address.
Max length: 4 characters
Address Line 1 Text
Please provide the first line of your postal address.
Address Line 2 Text
Please provide the second line of your postal address.
Address Line 3 Text
Please provide the third line of your postal address.
Postcode Text
Please provide the postal code for your address.
Max length: 4 characters
Second Parent or Guardian Declaration
Second Parent/Guardian Full Name Text
Provide the full name of the second parent or guardian. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
I have read, understood and agree to the above. Checkbox
Check this box if, as the second parent or guardian, you have read, understood, and agree to the declaration statements for this form. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Second Parent/Guardian Declaration Day Date
Enter the day of the second parent or guardian's declaration. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Second Parent/Guardian Declaration Month Date
Enter the month of the second parent or guardian's declaration. Fill only if 'Yes' is 'Yes'.
Max length: 2 characters
Depends on: Yes
Second Parent/Guardian Declaration Year Date
Enter the year of the second parent or guardian's declaration. Fill only if 'Yes' is 'Yes'.
Max length: 4 characters
Depends on: Yes
Second Person Copy/Transfer Inquiry
No Checkbox
Check this box if no second person needs to copy or transfer.
Yes Checkbox
Check this box if a second person needs to copy or transfer.
Third Person Copy/Transfer Inquiry
No Checkbox
Check this box if a third person does not need to copy or transfer. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Yes Checkbox
Check this box if a third person needs to copy or transfer. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Unlabeled Checkbox near Question 18
Question 18 No Details Text
Please provide any additional details or context for your 'No' answer to the question regarding Aboriginal or Torres Strait Islander Australian descent.
Unlabeled Checkbox near Question 9
No Aboriginal/Torres Strait Islander Descent Text
Please enter 'X' or 'Yes' if you are not of Aboriginal or Torres Strait Islander Australian descent, or leave blank otherwise.