PRIVATE PATIENTS ONLY

IMC (Inpatient Medical Claims) Patient Claim Consent & Declaration

Should you require future surgery this practice will electronically bill your Private Health Fund (if they are an electronic billing and GapCover participant) and Medicare for the services of our Specialist Obstetrician / Gynaecologist in theatre.  This practice participates

in the GapCover scheme, meaning you will have no out of pocket expense for the surgical component of your operation.

I have paid for, or am liable to pay for the expenses for these services, which are not excluded under the Health Insurance Act 1973 (i.e. not for the purpose of life insurance, superannuation or provident account schemes, admission to a friendly society, health screening, mass immunisation or connected with employment).

To the best of my knowledge and belief, all the information in this Claim is true and all information disclosed by me to the Medical Practice in the lodging of this Claim is true and accurate.

I authorise this Medical Practice to electronically transmit this Claim for Medicare Benefits (including banking details) to the Health Insurance Commission (Medicare Australia) and for Medicare Australia to forward the Claim details to the nominated Health Fund on my behalf.

I also authorise Medicare Australia or Health Fund to contact the referring practitioner or the provider of the services, if clarification of details for this account and/or receipt is required for assessment or auditing purposes.

For this Claim, I consent to this Medical Practice sending to and/or receiving from Medicare Australia and/or the nominated Health Fund, the following information for the purpose of verification and/or processing this Claim:

• patient’s Medicare enrolment information (including Medicare number, issue number and individual reference number) and
• patient’s first name, family name and date of birth,
• patient’s Health Fund information including the patient’s membership number or membership card number.

If Medicare pays a total benefit of zero for each service within this Claim, the whole claim will not be forwarded to the nominated Health Fund.

I acknowledge that it is a serious, criminal offence to give Medicare Australia false or misleading information in relation to a Medicare claim.

Privacy Note:  The information provided will be used to assess any Medicare benefit payable and/or Health Fund benefit payable for the services rendered and to facilitate the proper administration of Australian Government health programs.  Its collection is authorised by provisions of the Health Insurance Act 1973.  The information may be disclosed to the Department of Health and Ageing or to a person in the Medical Practice associated with this Claim, or to the Health Fund associated with this Claim, or as authorised / required by law.  Information about medical expense totals may also be disclosed to other authorised family members for taxation statement purposes and the monitoring of family safety net entitlements.  Patient name and address details may be disclosed to financial institutions when the claim is paid.