Medicare Enrolment Application (Australia) – Enrol in Medicare, Re-enrol/Extend Eligibility, Enrol a Newborn, and Register for My Health Record Instructions

Enter the full name of Additional Person 2 as part of the declaration.

Check this box if Additional Person 2 has read, understood, and agrees to the declaration.

Enter the day of the declaration date.

Enter the month of the declaration date.

Enter the year of the declaration date.

Enter the full name of Additional Person 3 as part of their declaration.

Check this box if Additional Person 3 has read, understood, and agrees to the declaration statements, which include confirming the information provided at question 142 is complete and correct and having read the Privacy notice at question 148.

Enter the day (DD) of the declaration date for Additional Person 3.

Enter the month (MM) of the declaration date for Additional Person 3.

Enter the year (YYYY) of the declaration date for Additional Person 3.

Check this box if Additional Person 4 is not of Aboriginal or Torres Strait Islander Australian descent.

Check this box if Additional Person 4 is of Aboriginal Australian descent.

Check this box if Additional Person 4 is of Torres Strait Islander Australian descent.

Check this box if Additional Person 4 is not of Australian South Sea Islander descent.

Check this box if Additional Person 4 is of Australian South Sea Islander descent.

Enter the name of the bank, building society, or credit union where additional person 4 holds their account.

Enter the Branch number (BSB) for the additional person 4's bank account.

Enter the bank account number for the additional person 4's bank account.

Enter the name(s) in which the additional person 4's bank account is held.

Check this box if Additional Person 4 does not want payments to be made into the nominated bank account at question 21.

Check this box if Additional Person 4 authorizes payments to be made into the nominated bank account at question 21.

Enter the full name of the additional person 4 for whom bank payment authorization is being given.

Enter the contact phone number for additional person 4, including the area code.

Enter the email address for additional person 4.

Provide the day of additional person 4's arrival in Australia.

Provide the month of additional person 4's arrival in Australia.

Provide the year of additional person 4's arrival in Australia.

Enter the day of birth for additional person 4.

Enter the month of birth for additional person 4.

Enter the year of birth for additional person 4.

Enter the full name of the additional person 4 making this declaration.

Check this box if Additional Person 4 has read, understood, and agrees to the declaration regarding the completeness and correctness of information provided at question 146, and has read the Privacy notice at question 148.

Enter the day the additional person 4's declaration was made, in DD format.

Enter the month the additional person 4's declaration was made, in MM format.

Enter the year the additional person 4's declaration was made.

Provide the full name of additional person 4 as it appears on the bank account for final authorization.

Check this box if Additional Person 4 identifies as male.

Check this box if Additional Person 4 identifies as female.

Check this box if Additional Person 4 identifies as non-binary.

Please enter the individual healthcare identifier for additional person 4.

Check this box if Additional Person 4 does not need an interpreter.

Check this box if Additional Person 4 needs an interpreter.

Enter the preferred spoken language for additional person 4 for interpreter services.

Enter the secondary spoken language for additional person 4 for interpreter services, if applicable.

Check this box if Additional Person 4 does not require a Lifetime Health Cover letter.

Check this box if Additional Person 4 requires a Lifetime Health Cover letter.

Check this box if Additional Person 4 has not previously been enrolled in Medicare.

Check this box if Additional Person 4 has previously been enrolled in Medicare.

Enter the first part of Additional Person 4's previous Medicare card number.

Enter the second part of Additional Person 4's previous Medicare card number.

Enter the third part of Additional Person 4's previous Medicare card number.

Enter the reference number associated with Additional Person 4's previous Medicare card.

Provide the title of Additional Person 4 if it is not Mr, Mrs, Miss, Ms, or Mx.

Enter the family name of Additional Person 4.

Enter the first given name of Additional Person 4.

Enter the second given name of Additional Person 4.

Check this box if Additional Person 4 has not previously lived overseas.

Check this box if Additional Person 4 has previously lived overseas.

Enter the name of the country where Additional Person 4 previously resided before arriving in Australia.

Enter the total number of years Additional Person 4 resided in the previous country.

Enter the total number of months Additional Person 4 resided in the previous country.

Check this box if Additional Person 4 does not have plans to reside in Australia permanently.

Enter the planned day of departure for additional person 4.

Enter the planned month of departure for additional person 4.

Enter the planned year of departure for additional person 4.

Check this box if Additional Person 4 has plans to reside in Australia permanently.

Check this box if Additional Person 4 has never used or been known by another name.

Check this box if Additional Person 4 has previously used or been known by another name.

Enter the full previous name of additional person 4.

Check this box if the person is not of Australian South Sea Islander descent.

Check this box if the person is of Australian South Sea Islander descent.

Check this box if the person is not of Australian South Sea Islander descent.

Check this box if the person is of Australian South Sea Islander descent.

Enter the full name of the bank, building society, or credit union where the account is held.

Enter the Branch State Bank (BSB) number for the bank account.

Enter the bank account number, ensuring it is not a card number.

Enter the full name(s) of the person or people in whose name the account is held.

Check this box if Additional Person 2 authorizes payments to be made into the bank account they have nominated.

Enter the full name of Additional Person 2 to authorize payments into the nominated bank account.

Enter the name of the bank, building society, or credit union where the account is held.

Enter the Branch number (BSB) of the bank account.

Enter the bank account number (this may not be the card number).

Enter the name(s) in which the bank account is held.

Check this box to authorize payments to be made into the bank account details you have provided in this form.

Enter the full name of additional person 1 to authorise payments into the nominated bank account.

Check this box if the child is not of Aboriginal or Torres Strait Islander Australian descent.

Check this box if the child is of Aboriginal Australian descent.

Check this box if the child is of Torres Strait Islander Australian descent.

Check this box if the child is not of Australian South Sea Islander descent.

Check this box if the child is of Australian South Sea Islander descent.

Enter the day of the child's date of birth.

Enter the month of the child's date of birth.

Enter the year of the child's date of birth.

Provide the child's family name.

Provide the child's first given name.

Provide the child's second given name.

Check this box if the child's sex is male.

Check this box if the child's sex is female.

Check this box if additional person 1 does not want payments to be made into the nominated bank account at question 21.

Check this box if additional person 1 authorises payments to be made into the nominated bank account at question 21.

Please provide the full name of additional person 1.

Enter the contact phone number for the additional person, including the area code.

Enter the email address for the additional person.

Please enter the day of arrival in Australia.

Please enter the month of arrival in Australia.

Please enter the year of arrival in Australia.

Enter the day of the additional person's birth.

Enter the month of the additional person's birth.

Enter the year of the additional person's birth.

Check this box to confirm that you have read, understood, and agree to the declaration points and terms outlined in section 149.

Enter the day of the declaration date.

Enter the month of the declaration date.

Enter the year of the declaration date.

Enter the full name of Additional Person 1 making this declaration.

Check this box to confirm that Additional Person 1 has read, understood, and agrees to the declaration statement, including the privacy notice, legal obligations, consent items, and understanding statements outlined in the form.

Enter the full name of additional person 4.

Check this box to confirm that Additional Person 4 has read, understood, and agrees to all the statements in the declaration.

Enter the person's full postal address (street number and name, unit or apartment if applicable) for mail delivery.

Check this box if the person is applying to enrol in Medicare for the first time as an Australian citizen

Check this box when first enrolling someone in Medicare if they are a child born outside Australia to an Australian citizen and you are providing the required birth and citizenship documents for that category.

Check this box if you are a New Zealand citizen living in Australia and will enrol in Medicare using your New Zealand passport and the required residency documents.

Check this box if you are enrolling for Medicare as a permanent resident of Australia who is not an Australian citizen and will provide the required proof of residency documents.

Check this box if you have lodged an application for permanent residency or a permanent protection visa and are applying for Medicare while that application is still pending.

Check this box if you are enrolling in Medicare as a visitor from a country that has a Reciprocal Health Care Agreement with Australia.

Check this box when enrolling in Medicare for the first time if you are not an Australian citizen but hold a visa covered by a Ministerial Order allowing you to access Medicare.

Check this box if you do not need a duplicate card.

Check this box if you need a duplicate card, meaning you will receive a second card with the same details.

Provide the total number of years this person resided in the previous overseas country.

Provide the total number of months this person resided in the previous overseas country, in addition to the years.

Check this box if the person identifies as male.

Check this box if the person identifies as female.

Check this box if the person identifies as non-binary.

Enter the first part of your previous Medicare card number, if known.

Enter the second part of your previous Medicare card number, if known.

Enter the third part of your previous Medicare card number, if known.

Enter the reference number associated with your previous Medicare card, if known.

Enter the first part of your current Medicare card number.

Enter the second part of your current Medicare card number.

Enter the third part of your current Medicare card number.

Enter the reference number associated with your current Medicare card.

Check this box if you are not of Aboriginal or Torres Strait Islander Australian descent.

Check this box if you are of Aboriginal Australian descent.

Check this box if you are of Torres Strait Islander Australian descent.

Check this box if you are not of Australian South Sea Islander descent.

Check this box if you are of Australian South Sea Islander descent.

Check this box if you have not previously lived overseas.

Check this box if you have previously lived overseas.

Enter the name of the country where you resided before arriving in Australia.

Enter the total number of years you resided in your previous country.

Enter the total number of months you resided in your previous country.

Enter the day you arrived in Australia.

Enter the month you arrived in Australia.

Enter the year you arrived in Australia.

Check this box if you do not have plans to reside in Australia permanently.

If known, enter the planned day of your departure.

If known, enter the planned month of your departure.

If known, enter the planned year of your departure.

Check this box if you do have plans to reside in Australia permanently.

Check this box if you do not require a Lifetime Health Cover letter.

Check this box if you do require a Lifetime Health Cover letter.

Enter the name of your bank, building society, or credit union.

Enter your Branch State Bank (BSB) number.

Enter your bank account number.

Enter the full name(s) of the person(s) in whose name the account is held.

Enter your full name as the person making this declaration.

Check this box to confirm that you have read, understood, and agree to the declaration made in section 23.

Enter the day (DD) of the date you are making this declaration.

Enter the month (MM) of the date you are making this declaration.

Enter the year (YYYY) of the date you are making this declaration.

Check this box if there are no other people to be enrolled on your Medicare card, prompting you to go to Part D.

Check this box if there are other people to be enrolled on your Medicare card, prompting you to go to Part B.

Check this box if additional person 1 has not previously been enrolled in Medicare.

Check this box if additional person 1 has previously been enrolled in Medicare.

Enter the first numerical segment of Additional Person 1's previous Medicare card number.

Enter the second numerical segment of Additional Person 1's previous Medicare card number.

Enter the third numerical segment of Additional Person 1's previous Medicare card number.

Enter the reference number associated with Additional Person 1's previous Medicare card.

Check this box if additional person 1's title is Mr.

Check this box if additional person 1's title is Mrs.

Check this box if additional person 1's title is Miss.

Check this box if additional person 1's title is Ms.

Check this box if additional person 1's title is Mx.

If the 'Other' option is selected for Additional Person 1's title, please specify it here.

Enter the family name of Additional Person 1.

Enter the first given name of Additional Person 1.

Enter the second given name of Additional Person 1, if applicable.

Check this box if additional person 1 has never used or been known by another name.

Check this box if additional person 1 has ever used or been known by another name.

Provide details of any previous name(s) by which Additional Person 1 has been known.

Enter the day (DD) of birth for Additional Person 1.

Enter the month (MM) of birth for Additional Person 1.

Enter the year (YYYY) of birth for Additional Person 1.

Check this box if additional person 1's gender is Male.

Check this box if additional person 1's gender is Female.

Check this box if additional person 1's gender is Non-binary.

Enter the contact phone number for Additional Person 1, including the area code.

Enter the email address for Additional Person 1.

Check this box if additional person 1 does not need an interpreter.

Check this box if additional person 1 needs an interpreter.

Enter the preferred spoken language for Additional Person 1.

Enter the secondary spoken language for Additional Person 1, if applicable.

Enter the final digit(s) of Additional Person 1's Individual Healthcare Identifier.

Check this box if additional person 1 is not of Aboriginal or Torres Strait Islander Australian descent.

Check this box if additional person 1 is of Aboriginal Australian descent.

Check this box if additional person 1 is of Torres Strait Islander Australian descent.

Provide the full name of additional person 2.

Check this box if additional person 2 has read, understood, and agrees to the declaration.

Check this box if additional person 3 has not previously been enrolled in Medicare.

Check this box if additional person 3 has previously been enrolled in Medicare.

Enter the first part of additional person 3's previous Medicare card number.

Enter the second part of additional person 3's previous Medicare card number.

Enter the third part of additional person 3's previous Medicare card number.

Enter the reference number for additional person 3's previous Medicare card.

Check this box if additional person 3's title is Mr.

Check this box if additional person 3's title is Mrs.

Check this box if additional person 3's title is Miss.

Check this box if additional person 3's title is Ms.

Check this box if additional person 3's title is Mx.

If 'Other' is selected for title, specify additional person 3's title.

Enter the family name of additional person 3.

Enter the first given name of additional person 3.

Enter the second given name of additional person 3.

Check this box if additional person 3 has never used or been known by another name.

Check this box if additional person 3 has previously used or been known by another name.

Provide details of any previous name used by additional person 3.

Enter the day of additional person 3's birth.

Enter the month of additional person 3's birth.

Enter the year of additional person 3's birth.

Check this box if additional person 3's gender is Male.

Check this box if additional person 3's gender is Female.

Check this box if additional person 3's gender is Non-binary.

Enter the contact phone number, including the area code, for additional person 3.

Enter the email address for additional person 3.

Check this box if additional person 3 does not need an interpreter.

Check this box if additional person 3 needs an interpreter.

Specify additional person 3's preferred spoken language for an interpreter.

Specify additional person 3's secondary spoken language if applicable.

Enter the last digit of additional person 3's Individual Healthcare Identifier.

Check this box if additional person 3 is not of Aboriginal or Torres Strait Islander Australian descent.

Check this box if additional person 3 is of Aboriginal Australian descent.

Check this box if additional person 3 is of Torres Strait Islander Australian descent.

Check this box if additional person 3 is not of Australian South Sea Islander descent.

Check this box if additional person 3 is of Australian South Sea Islander descent.

Check this box if the person has not previously lived overseas.

Check this box if the person has previously lived overseas.

Enter the previous country of residence before arriving in Australia.

Enter the total number of years this person was residing in their previous country.

Enter the total number of months this person was residing in their previous country.

Enter the day of arrival in Australia.

Enter the month of arrival in Australia.

Enter the year of arrival in Australia.

Check this box if the person does not have plans to reside in Australia permanently.

Enter the planned day of departure from Australia, if known.

Enter the planned month of departure from Australia, if known.

Enter the planned year of departure from Australia, if known.

Check this box if the person has plans to reside in Australia permanently.

Check this box if the person does not require a Lifetime Health Cover letter.

Check this box if the person requires a Lifetime Health Cover letter.

Check this box if you do not want payments to be made into the nominated bank account at question 21.

Check this box if you authorise for payments to be made into the bank account at question 21.

Enter the full name of additional person 3 who authorizes payments to be made into the bank account specified in question 21.

Enter the name of the bank, building society, or credit union (Australian financial institutions only).

Enter the Branch number (BSB) of the bank account.

Enter the bank account number.

Enter the full name(s) of the account holder(s).

Check this box to authorise for payments to be made into the bank account you have nominated above.

Enter the full name of additional person 3 who authorizes payments to be made into the bank account nominated in question 80.

Enter the full name of additional person 3 completing the declaration in question 81.

Check this box to confirm that you have read, understood, and agree to the terms and conditions outlined in section 81.

Enter the first part of your Medicare card number.

Enter the second part of your Medicare card number.

Enter the third part of your Medicare card number.

Enter the reference number associated with your Medicare card.

Check this box if your title is Mr.

Check this box if your title is Mrs.

Check this box if your title is Miss.

Check this box if your title is Ms.

Check this box if your title is Mx.

Specify your title if it is not Mr, Mrs, Miss, Ms, or Mx.

Enter your family name.

Enter your first given name.

Enter your second given name.

Check this box if you have never used or been known by another name.

Check this box if you have previously used or been known by another name.

Provide details of any other names you have used or been known by.

Enter the day of your birth.

Enter the month of your birth.

Enter the four-digit year of your birth.

Check this box if your relationship to the child is 'Birth mother'.

Check this box if your relationship to the child is 'Biological father'.

Check this box if your relationship to the child is 'Other' than birth mother or biological father.

Provide details if your relationship to the child is not Birth mother or Biological father.

Enter the first line of your current postal address.

Enter the second line of your current postal address, such as suburb or town.

Enter your postal code.

Enter your contact phone number, including the area code.

Enter your email address.

Check this box if you do not need an interpreter.

Check this box if you need an interpreter.

Enter your preferred spoken language if you require an interpreter.

Enter your secondary spoken language if applicable.

Check this box if you do not have a partner.

Check this box if you have a partner.

Check this box if your partner is not listed on your Medicare card.

Check this box if your partner is listed on your Medicare card.

Check this box if you do not need a duplicate card.

Check this box if you need a duplicate card.

Check this box if your partner does not want the newborn child to be added to their Medicare card.

Check this box if your partner wants the newborn child to be added to their Medicare card.

Enter the first part of your partner's Medicare card number.

Enter the second part of your partner's Medicare card number.

Enter the third part of your partner's Medicare card number.

Enter the reference number associated with your partner's Medicare card.

Check this box if your partner's title is Mr.

Check this box if your partner's title is Mrs.

Check this box if your partner's title is Miss.

Check this box if your partner's title is Ms.

Check this box if your partner's title is Mx.

Specify your partner's title if it is not Mr, Mrs, Miss, Ms, or Mx.

Enter your partner's family name.

Enter your partner's first given name.

Enter your partner's second given name.

Check this box if you are not using this form to enrol yourself in Medicare.

Check this box if you are using this form to enrol yourself in Medicare.

Check this box if you do not want a My Health Record for yourself.

Check this box if you want a My Health Record for yourself.

Check this box if you are not using this form to enrol additional people in Medicare.

Check this box if you are using this form to enrol additional people in Medicare.

Check this box if you do not want to give Additional person 1 a My Health Record.

Check this box if you want to give Additional person 1 a My Health Record.

Enter the full name of Additional Person 1 for their declaration.

Check this box to declare that for Additional person 1, you have read, understood, and agree to the provided information.

Enter the day of the declaration date.

Enter the month of the declaration date.

Enter the year of the declaration date.

Check this box if there are no other additional people listed in Part B of this form.

Check this box if there are other additional people listed in Part B of this form.

Provide the individual healthcare identifier for the person, if applicable.

Check this box if there are no other additional people to be listed in Part B of this form after Additional Person 2.

Check this box if there are other additional people to be listed in Part B of this form after Additional Person 2.

Check this box if there are no other additional people listed in Part B of this form after Additional Person 3.

Check this box if there are other additional people listed in Part B of this form after Additional Person 3.

Check this box if the additional person does not need an interpreter.

Check this box if the additional person needs an interpreter.

Enter the person's primary preferred spoken language.

Enter the person's secondary spoken language, if applicable.

Check this box if the person does not require a Lifetime Health Cover letter.

Check this box if the person requires a Lifetime Health Cover letter.

Check this box if the person does not require a Lifetime Health Cover letter.

Check this box if the person does require a Lifetime Health Cover letter.

Check this box if additional person 2 has not previously been enrolled in Medicare.

Check this box if additional person 2 has previously been enrolled in Medicare.

Enter the first part of the additional person's previous Medicare card number.

Enter the second part of the additional person's previous Medicare card number.

Enter the third part of the additional person's previous Medicare card number.

Enter the reference number associated with the additional person's previous Medicare card.

Check this box if you do not want an additional person 2 to be given a My Health Record.

Check this box if you want an additional person 2 to be given a My Health Record.

Check this box if you do not want to give Additional Person 3 a My Health Record.

Check this box if you want to give Additional Person 3 a My Health Record.

Check this box if you do not want to give Additional Person 4 a My Health Record.

Check this box if you want to give Additional Person 4 a My Health Record.

Check this box if the additional person 2 uses the title Mr.

Check this box if the additional person 2 uses the title Mrs.

Check this box if the additional person 2 uses the title Miss.

Check this box if the additional person 2 uses the title Ms.

Check this box if the additional person 2 uses the title Mx.

Enter any other title or gender prefix for additional person 2 if 'Mr', 'Mrs', 'Miss', 'Ms', or 'Mx' are not applicable.

Provide the family name of additional person 2.

Provide the first given name of additional person 2.

Provide the second given name of additional person 2.

Check this box if you do not want your newborn child added to your Medicare Safety Net family registration.

Check this box if you want your newborn child added to your Medicare Safety Net family registration.

Check this box if you do not want your newborn child to have a My Health Record.

Check this box if you want your newborn child to have a My Health Record.

Check this box if additional person 2 has not previously lived overseas.

Check this box if additional person 2 has previously lived overseas.

Enter the name of the country where this person previously resided before arriving in Australia.

Enter the total number of years this person resided in the previous country.

Enter the total number of months this person resided in the previous country.

Enter the day of arrival in Australia.

Enter the month of arrival in Australia.

Enter the year of arrival in Australia.

Enter the day of your partner's date of birth.

Enter the month of your partner's date of birth.

Enter the four-digit year of your partner's date of birth.

Check this box if the partner has read, understood, and agrees to the terms outlined in the declaration section.

Enter the day of the partner's declaration date.

Enter the month of the partner's declaration date.

Enter the year of the partner's declaration date.

Enter the full name of the partner.

Enter the first part of your partner's Medicare Card Number.

Enter the second part of your partner's Medicare Card Number.

Enter the third part of your partner's Medicare Card Number.

Enter the reference number for your partner's Medicare Card.

Check this box if you do not want your partner added to your Medicare Safety Net family registration.

Check this box if you want your partner added to your Medicare Safety Net family registration.

Check this box if your partner has never used or been known by another name.

Check this box if your partner has ever used or been known by another name.

Provide your partner's previous full name if they have used or been known by another name.

Check this box if your partner is the birth mother of the child.

Check this box if your partner is the biological father of the child.

Check this box if your partner's relationship to the child is not 'Birth mother' or 'Biological father', and provide details in the adjacent field.

Provide a detailed description of your partner's relationship to this child, if it is not 'Birth mother' or 'Biological father'.

Check this box if you do not want payments to be made into the nominated bank account at question 21.

Check this box if you authorize for payments to be made into the nominated bank account at question 21.

Enter the full name of additional person 2 for whom payment authorization is being provided.

Check this box if the person does not have plans to reside in Australia permanently.

Check this box if the person has plans to reside in Australia permanently.

Check this box if the person does not have plans to reside in Australia permanently.

Please enter the day of the planned departure date.

Please enter the month of the planned departure date.

Please enter the year of the planned departure date.

Check this box if the person has plans to reside in Australia permanently.

Enter the day of the planned date of departure.

Enter the month of the planned date of departure.

Enter the year of the planned date of departure.

Enter the name of the country where the person previously resided before arriving in Australia.

Check this box if the additional person has never used or been known by another name.

Check this box if the additional person has ever used or been known by another name.

Provide the full previous name of the person.

Check this box if the person has not previously lived overseas.

Check this box if the person has previously lived overseas.

Check this box if you are enrolling in Medicare for the first time or you are a returning visitor from a country with a Reciprocal Health Care Agreement who has previously been enrolled in Medicare (applicable to persons aged 12 months and older and newborn children born overseas).

Check this box if you are returning to Australia, or an Interim or Reciprocal Medicare card holder who has not left Australia, and you need to re-enrol in Medicare or extend your Medicare eligibility.

Check this box if you are enrolling a newborn child who is under one year old and was born in Australia.

Check this box if you are registering for a My Health Record and should proceed directly to the My Health Record section of the form.

Check this box to confirm that you have read, understood, and agree to the privacy notice and all statements made in the declaration section above.

Enter the day of the declaration date.

Enter the month of the declaration date.

Enter the year of the declaration date.

Please enter your complete legal full name.