Db2 Gp Form – Fill Out and Use This PDF

The DB2-GP form is a critical document designed exclusively for use by general practitioners to assign Medicare benefits for services provided. It ensures that each patient's claim is processed accurately, requiring specific steps like imprinting the Medicare Card, completing relevant sections, and obtaining the patient's signature after completion. For a smooth and efficient way to handle Medicare assignments, click the button below to fill out the form.

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Db2 Gp Form PDF Details

Navigating through the intricacies of healthcare documentation is pivotal for ensuring that patients and practitioners alike are well-informed and appropriately compensated for medical services. The LEIGH-MARDON Medicare Assignment Form, designated for use by General Practitioners only (DB2-GP), serves as a prime example of such a document that bridges the gap between healthcare services provided and the administrative requirements set by Medicare. This form, detailed in its instructions, mandates that for each patient visit, a separate form needs to be filled out, emphasizing the need for accuracy and precision in documenting the patient's details, the service date, and specifics of the medical service rendered, including the consultation level. An interesting aspect of this system is the tri-part form designed to ensure that all stakeholders, including Medicare, the practitioner, and the patient, retain a copy, thus maintaining transparency and accountability. Additionally, the form has provisions that cater to visitors under the Reciprocal Health Care Agreement (RHCA), limiting benefits to immediately necessary medical care, showcasing the adaptability of Medicare's administrative processes to various patient circumstances. The privacy note attached underlines the importance of data protection and outlines the permissible use of the information collected, which is a crucial facet of modern healthcare interactions. Designed with both functionality and legal compliance in mind, as dictated by the Health Insurance Act 1973, it not only facilitates the proper administration of Australian Government health programs but also ensures that the enrolment records are up-to-date, showcasing a commitment to maintaining the integrity of patient data while streamlining the process of healthcare reimbursement.

Question	Answer
Form Name	Db2 Gp Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	db2 medicare, medicare db2 claim form, medicare assignment form db2 gp, australia medicare forms

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LEIGH-MARDON

MEDICARE ASSIGNMENT FORM FOR USE BY GENERAL PRACTITIONERS ONLY	DB2-GP

DO NOT REMOVE COVER SHEET BEFORE IMPRINTING

1.Only one patient is allowed per form.

2.Check date of service is before expiry date by placing an X in the box provided.

3.A Card with VISITOR RHCA indicates Medicare will only pay benefits for IMMEDIATELY NECESSARY MEDICAL CARE.

4.When completing the voucher use the following steps:

(a)Imprint the Medicare Card

(b)Remove the cover sheet

(c)Complete the relevant sections of the forms making sure information entered into a box is completely within

the box. EXAMPLE 1 2 3 4 5 OR 1 2 / 0 2 / 0 6 OR X

(d)If the service is one of the pre-printed services place an X as indicated on the form.

(e)If the service is not one of the pre-printed services write the Item Number or Description of Service in the space provided.

5.Patient MUST sign the form AFTER the form has been completed.

6.Send the RED copy to Medicare, keep the BLACK copy for your records and give the GREEN copy to the patient.

Designed: 03/06

PRIVACY NOTE: The information provided will be used to assess any Medicare benefit payable for the services rendered and to facilitate the proper administration of Australian Government health programs and may be used to update enrolment records. Its collection is authorised by provisions of the HEALTH INSURANCE ACT 1973. The information may be disclosed to the Department of Health and Ageing, Department of Human Services, Centrelink, other relevant agencies or to a person in the medical practice associated with this claim or as authorised/required by law.

– PLEASE COMPLETE THIS FORM IN BLACK BALLPOINT PEN –

REF.No

FIRST NAME

INITIAL

SURNAME

ASSIGNMENT

(This form is the approved form as

REF. No.

FIRST NAME

INITIAL

SURNAME

MEDICARE

FORM

prescribed under section 20A of

DB2-GP

the Health Insurance Act 1973)

DATE OF BIRTH

PATIENT

DATE OF SERVICE

RESIDENTIAL ADDRESS

REF. No.

DD / MM / YY

DESCRIPTION OF SERVICE

ITEM NO.

BENEFIT ASSIGNED

CONSULTATION:

VALID TO

LEVEL A

DATE

CONSULTATION:

CHECKED

LEVEL B

MEDICARE NUMBER IF IMPRINTER NOT USED

CONSULTATION:

LEVEL C

STANDARD

CONSULTATION

PRACTITIONER USE

I assign my right to benefits to the practitioner

NAME & PROVIDER No. OR ADDRESS OF PRACTITIONER

No. OF

who has rendered the service(s).

WHO RENDERED THE ABOVE SERVICE(S)

PATIENTS

ATTENDED

SIGNATURE OF PATIENT

DATE

MEDICARE COPY	Designed 03/06 Printed /06

HOLD BOTH ENDS FIRMLY – PULL TO SEPARATE

A S S I G N M E N T

O R M

P	– PLEASE COMPLETE THIS FORM IN BLACK BALLPOINT PEN –

REF.No

FIRST NAME

INITIAL

SURNAME

ASSIGNMENT

(This form is the approved form as

REF. No.

FIRST NAME

INITIAL

SURNAME

MEDICARE

FORM

prescribed under section 20A of

DB2-GP

the Health Insurance Act 1973)

DATE OF BIRTH

PATIENT

DATE OF SERVICE

RESIDENTIAL ADDRESS

REF. No.

DD / MM / YY

DESCRIPTION OF SERVICE

ITEM NO.

BENEFIT ASSIGNED

CONSULTATION:

VALID TO

LEVEL A

DATE

CONSULTATION:

CHECKED

LEVEL B

MEDICARE NUMBER IF IMPRINTER NOT USED

CONSULTATION:

LEVEL C

STANDARD

CONSULTATION

PRACTITIONER USE

I assign my right to benefits to the practitioner

NAME & PROVIDER No. OR ADDRESS OF PRACTITIONER

No. OF

who has rendered the service(s).

WHO RENDERED THE ABOVE SERVICE(S)

PATIENTS

ATTENDED

SIGNATURE OF PATIENT

DATE

PRACTITIONER COPY	Designed 03/06

HOLD BOTH ENDS FIRMLY – PULL TO SEPARATE

A S S I G N M E N T

O R M

– PLEASE COMPLETE THIS FORM IN BLACK BALLPOINT PEN –

REF.No

FIRST NAME

INITIAL

SURNAME

ASSIGNMENT

(This form is the approved form as

REF. No.

FIRST NAME

INITIAL

SURNAME

MEDICARE

FORM

prescribed under section 20A of

DB2-GP

the Health Insurance Act 1973)

DATE OF BIRTH

PATIENT

DATE OF SERVICE

RESIDENTIAL ADDRESS

REF. No.

DD / MM / YY

DESCRIPTION OF SERVICE

ITEM NO.

BENEFIT ASSIGNED

CONSULTATION:

VALID TO

LEVEL A

DATE

CONSULTATION:

CHECKED

LEVEL B

MEDICARE NUMBER IF IMPRINTER NOT USED

CONSULTATION:

LEVEL C

STANDARD

CONSULTATION

PRACTITIONER USE

I assign my right to benefits to the practitioner

NAME & PROVIDER No. OR ADDRESS OF PRACTITIONER

No. OF

who has rendered the service(s).

WHO RENDERED THE ABOVE SERVICE(S)

PATIENTS

ATTENDED

SIGNATURE OF PATIENT

DATE

PATIENT COPY	Designed 03/06

HOLD BOTH ENDS FIRMLY – PULL TO SEPARATE

A S S I G N M E N T

O R M

Db2 Gp Form – Fill Out and Use This PDF

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