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Practice Forms

Find below a range of useful forms for General Practices. These links direct you directly to the original locations of the files to ensure you are accessing the most up to date version. Please report any errors or make suggestions for forms that should be included to web.admin@racgp.org.au

Quick Links
Medicare Australia
Pharmaceutical Benefits Scheme
Australian Childhood Immunisation Register
Department of Veterans Affairs
Consumer Forms

Medicare Australia

Application for Recognition as a GP (RACGP Fellows)
Since 1 November 1993, Fellows of the RACGP have been able to access the Group A1 attendance items (Items 3-51) in the Medicare Benefits Schedule. These items, formerly reserved for Vocationally Registered general practitioners, are to be called General Practitioner Attendance Items and may be used by medical practitioners on the Vocational Register, Fellows of the RACGP, Registrars in general practice during their general practice placement terms and Rural Other Medical Practitioners. Fellows wishing to gain access to General Practice Attendance Items must apply to HIC for recognition as a general practitioner for purposes of Medicare.

Application for Recognition as a GP (RACGP Fellows) PDF 379Kb- Less than 1 minute to download on a 56K modem.

VR of GP's Certification of Eligibility
Apply to have your name included on the Vocational Register of General Practitioners.

VR of GP's Certification of Eligibility PDF 379Kb - Less than 1 minute to download on a 56K modem.

90 Day Pay Doctor Cheque Scheme Application Form
From July 2001, HIC will be able to automatically cancel Medicare cheques made payable to an eligible General Practitioner via the claimant when they remain unpresented after 90 days, and pay benefits directly into GPs' financial institution accounts. Eligible GPs will need to apply to HIC to register for the 90 Day Pay Doctor Cheque Scheme.

90 Day Pay Doctor Cheque Scheme Application Form PDF 379Kb- Less than 1 minute to download on a 56K modem.

Application for Late Lodgement of a Claim for Assigned Medicare Benefits
Section 20B of the Health Insurance Act 1973 provides that Medicare benefits are not payable where a claim is lodged outside certain limits. In the case of assigned Medicare benefits, a claim must be lodged with the Health Insurance Commission within six(6) months of the date of a professional service.

Application for Late Lodgement of a Claim for Assigned Medicare Benefits PDF 379Kb- Less than 1 minute to download on a 56K modem.

Pharmaceutical Benefits Scheme

Application for Approval to Supply Pharmaceutical Benefits by a Registered Medical Practitioner
A medical practitioner may be granted approval to supply pharmaceutical benefits in an area in which an approved pharmacist is unable to supply a convenient and efficient pharmaceutical service. In order to apply for such an approval in respect of an area in which you are currently practising, or in which you intend to practise.

Application for Approval to Supply Pharmaceutical Benefits by a Registered Medical Practitioner PDF 379Kb- Less than 1 minute to download on a 56K modem.

Australian Childhood Immunisation Register

Application to Register as an Immunisation Provider Immunisation Providers must register with the ACIR before sending immunisation data. Public Sector providers must complete this form and forward it to their State/Territory Health Department for approval. General practitioners are automatically registered with the ACIR when they receive their Medicare Provider Number.

Application to Register as an Immunisation Provider PDF 379Kb- Less than 1 minute to download on a 56K modem.

Payment Account Details for Immunisation Providers
General practitioners must complete this form to receive payment for immunisation data sent to the ACIR. Other immunisation providers may update their bank account or credit union details recorded on the ACIR using this form.

Payment Account Details for Immunisation Providers PDF 379Kb- Less than 1 minute to download on a 56K modem.

NT, QLD and ACT Stationery Re-order Form Used by Northern Territory, Queensland and Australian Capital Territory immunisation providers to order immunisation stationery from the ACIR.

NT, QLD and ACT Stationery Re-order Form PDF 379Kb- Less than 1 minute to download on a 56K modem.

Stationery Re-order Form
All States and Territories, excluding Northern Territory, Queensland and Australian Capital Territory, should use this form to order immunisation stationery.

Stationery Re-order Form PDF 379Kb- Less than 1 minute to download on a 56K modem.

Application to Transmit Immunisation Data Electronically
Must be completed before immunisation data will be accepted via Electronic Data Interchange (EDI).

Application to Transmit Immunisation Data Electronically PDF 379Kb- Less than 1 minute to download on a 56K modem.

Medical Contraindication Form
Used by recognised immunisation providers if there is a reason why a vaccine should not be given to a child.

Medical Contraindication Form PDF 151Kb- Less than 1 minute to download on a 56K modem.

Conscientious Objection Form
Used to record a parent's conscientious objection to their child being immunised. This form must be completed by a parent or guardian together with the immunisation provider and sent to the ACIR.

Conscientious Objection Form PDF 178Kb- Less than 1 minute to download on a 56K modem

Department of Veterans Affairs

Application to be a Local Medical Officer (D1065) This form is used to assess applications to be a DVA Local Medical Officer (LMO).

Application to be a Local Medical Officer PDF 25Kb- Less than 1 minute to download on a 56K modem.

Application for Refund or Payment of Privately Incurred Medical Expenses (D1181)
This form is used by patients to claim for out-of-pocket medical expenses.

Application for Refune or Payment of Privately Incurred Medical Expenses PDF 17Kb- Less than 1 minute to download on a 56K modem.

Diagnostic Report - Anxiety Disorder or Depressive Disorder (D0401) This form collects information that will assist in deciding eligibility for benefits under the Veterans' Entitlements Act 1986 for treatment of anxiety/depressive disorder.

Diagnostic Report - Anxiety Disorder or Depressive Disorder PDF 15Kb- Less than 1 minute to download on a 56K modem.

Veterans1 Vocational Rehabilitation Scheme Application Form (D1000)
This form is used by veterans to apply for assistance under the Veterans1 Vocational Rehabilitation Scheme. The information in it is used to determine eligibility for assistance. It also provides introductory information about the veteran's vocational needs. This voluntary scheme assists veterans to find or continue in suitable employment.

Veterans1 Vocational Rehabilitation Scheme Application Form PDF 8Kb- Less than 1 minute to download on a 56K modem.

Authority to Release Personal Information - Vietnam Veterans Treatment of Depressive - Anxiety Disorder (D0400)
This form authorises the Repatriation Commission and DVA to obtain medical and other information that would aid the Repatriation Commission in determining if Vietnam veterans suffer from an anxiety or depressive disorder.

Vietnam Veterans Treatment of Depressive - Anxiety Disorder PDF 8Kb- Less than 1 minute to download on a 56K modem.

Consumer Forms

Medicare Enrolment Form Consumer Medicare Enrolment information.

Medicare Enrolment Form PDF 21Kb- Less than 1 minute to download on a 56K modem.

Medicare Enrolment Amendment Form
Change of address or request for duplicate/replacement Medicare card.

Medicare Enrolment Amendment Form PDF 8Kb- Less than 1 minute to download on a 56K modem.

Medicare Claim Form An online version of the form for claim and payment details.

Medicare Claim Form PDF 15Kb- Less than 1 minute to download on a 56K modem.

Medicare Change of Address Form
It is important to keep your Medicare address up to date. Use this form to notify Medicare of a change in address.

Medicare Change of Address Form PDF 8Kb- Less than 1 minute to download on a 56K modem.

Medicare Card Replacement Form
Complete this form to apply for the replacement of your Medicare card if it has expired or is about to expire.

Medicare Care Replacement Form PDF 8Kb- Less than 1 minute to download on a 56K modem.

Medicare Safety Net Registration Form
Safety Net family registration/change form.

Medicare Safety Net Registration Form PDF 50Kb- Less than 1 minute to download on a 56K modem.

Medicare Copy/Transfer Application form
Form to request a duplicate copy of a Medicare card or transfer of details from a current Medicare card to another Medicare card.

Medicare Copy/Transfer Application form PDF 61Kb- Less than 1 minute to download on a 56K modem.

Medicare Levy Exemption Certification Form
The Income Tax Assessment Act 1936 makes the Medicare Levy payable by individuals residing in Australia who are eligible for Medicare. Persons who are not entitled to Medicare can seek an exemption to the Medicare Levy in their income tax return.

Medicare Levy Exemption Certification Form PDF 61Kb- Less than 1 minute to download on a 56K modem.

Medicare Two Way Form
Private health fund claim/change of address form.

Medicare Two Way Form PDF 110Kb- Less than 1 minute to download on a 56K modem.

Request for Financial Statement Form
You will need a financial statement if your medical expenditure exceeds the current threshold set by the Australian Taxation Office (ATO) for tax purposes and you are required to show this expenditure on your tax return.

Request for Financial Statement Form

Publication Date: 23 June 2008