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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

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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