CONSENT FORM FOR MEDICARE CLIENTS

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Consent Form

Please complete the form below prior to your following consultation, if you are planning to claim Medicare rebates under your Mental Health Care Plan.

Personal Details
Your Name*
First Last
E-mail*
We will send you a copy of this consent form.
Your Referral or Mental Health Care Plan
Please upload a copy of your Mental Health Care Plan below. Alternatively please ask your Medical Centre to fax your referral through to us on 07 3172 4605.
Upload your document here
Drop files here or
Medicare Details
Medicare Number*
Individual Reference Number*
Number next to your name on your Medicare card.
Medicare Expiry Date*
GP or Doctor's Name*
Bank Account Details for Medicare Rebates
In most instances paid accounts can be electronically submitted to Medicare on your behalf and Medicare will deposit the rebate amount directly into your nominated bank account.
Account Name
Branch Code (BSB)
Account Number
Client Agreement
I/We*
Please type YOUR NAME in block capitals
*
- understand that my personal information will be used to assist in treatment and will not be passed on to any third person or agency without permission. I/We understand that consent can be withdrawn at any time. I/We give permission to the treating psychologist to obtain/release my personal information to the following individuals and agencies:
Referring GP or Doctor*
Agreement Date*
Comments
This field is for validation purposes and should be left unchanged.

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