Pharmaceutical Benefits Scheme (PBS) Safety Net application and amendment for a PBS Safety Net card form Instructions

Please provide the first line of your current residential address, including street number and street name.

Please provide the second line of your current residential address, which may include suburb, town, or unit number if applicable.

Please enter the postcode for your current residential address.

Provide the applicant's family name.

Provide the applicant's first given name.

Provide the applicant's second given name, if applicable.

Provide the applicant's full legal signature.

Enter the two-digit day of the date the form was signed.

Enter the two-digit month of the date the form was signed.

Enter the four-digit year of the date the form was signed.

Please provide your daytime phone number, including the area code.

Enter the family name of Family Member 1.

Enter the first given name of Family Member 1.

Enter the first part of Family Member 1's Medicare card number.

Enter the second part of Family Member 1's Medicare card number.

Enter the third part of Family Member 1's Medicare card number.

Enter the reference number found on Family Member 1's Medicare card.

Enter the day of birth for Family Member 1.

Enter the month of birth for Family Member 1.

Enter the year of birth for Family Member 1.

Enter the relationship code for Family Member 1 based on the provided definitions.

Please enter the family name of Family Member 2.

Please enter the first given name of Family Member 2.

Please enter the first segment of Family Member 2's Medicare card number.

Please enter the second segment of Family Member 2's Medicare card number.

Please enter the third segment of Family Member 2's Medicare card number.

Please enter the reference number for Family Member 2's Medicare card.

Please enter the day of birth for Family Member 2.

Please enter the month of birth for Family Member 2.

Please enter the year of birth for Family Member 2.

Please enter the relationship code that describes Family Member 2's relationship to the primary cardholder (e.g., SP, DC, DS).

Please enter the family name of family member 3.

Please enter the first given name of family member 3.

Please enter the first part of family member 3's Medicare card number.

Please enter the second part of family member 3's Medicare card number.

Please enter the third part of family member 3's Medicare card number.

Please enter the reference number associated with family member 3's Medicare card.

Please enter the day component of family member 3's date of birth.

Please enter the month component of family member 3's date of birth.

Please enter the year component of family member 3's date of birth.

Please enter the relationship code for family member 3.

Provide the family name of family member 4.

Provide the first given name of family member 4.

Provide the first four digits of family member 4's Medicare card number.

Provide the middle three digits of family member 4's Medicare card number.

Provide the final three digits of family member 4's Medicare card number.

Provide the reference number associated with family member 4's Medicare card.

Provide the day of birth for family member 4.

Provide the month of birth for family member 4.

Provide the year of birth for family member 4.

Provide the relationship code for family member 4 relative to the primary cardholder.

Enter the family name of family member 5.

Enter the first given name of family member 5.

Enter the first part of family member 5's Medicare card number.

Enter the second part of family member 5's Medicare card number.

Enter the third part of family member 5's Medicare card number.

Enter the reference number associated with family member 5's Medicare card.

Enter the day of birth for family member 5.

Enter the month of birth for family member 5.

Enter the year of birth for family member 5.

Enter the relationship code for family member 5, choosing from the provided options (SP, DC, DS).

Check this box if the family member does not need their own PBS Safety Net card.

Check this box if the family member needs their own PBS Safety Net card.

Enter the first set of digits from your Medicare card number.

Enter the second set of digits from your Medicare card number.

Enter the third set of digits from your Medicare card number.

Enter the individual reference number from your Medicare card, typically a single digit.

Check this box if the replacement card is needed because the original card was lost. Fill only if 'Replacement card' is 'Yes'.

Check this box if the replacement card is needed because the original card was stolen. Fill only if 'Replacement card' is 'Yes'.

Check this box if the replacement card is needed because the original card is damaged. Fill only if 'Replacement card' is 'Yes'.

Check this box if the replacement card is needed because the original card was destroyed. Fill only if 'Replacement card' is 'Yes'.

Check this box if the replacement card is needed to amend incorrect or outdated details. Fill only if 'Replacement card' is 'Yes'.

Check this box if a replacement card is needed to add a family member. Fill only if 'Replacement card' is 'Yes'.

Check this box if your spouse or partner needs a copy of your family's Safety Net card. Fill only if 'Supplementary card' is 'Yes'.

Check this box if a child or student named on your family's Safety Net card needs a separate card (for example, if they live away from home). Fill only if 'Supplementary card' is 'Yes'.

Check this box if you would like to request a replacement PBS Safety Net card.

Check this box if you would like to request a supplementary PBS Safety Net card.

Please provide the Safety Net number, which is printed on your PBS Safety Net Entitlement card (SN) or PBS Safety Net Concession card (CN).