CONSENT FORM FOR MEDICARE BETTER ACCESS - Brisbane City Psychologists

Consent Form

Please complete the consent form below to allow your psychologist to report back to your GP or Psychiatrist under the Medicare Better Access program, and for Brisbane City Psychologists to process your Medicare rebates online.

Personal Details
Full Name*
First Middle Last
E-mail*
We will send you a copy of this consent form.
Your Referral or Mental Health Care Plan
If you haven't yet provided our practice with a copy of your Mental Health Care Plan or referral, please upload a copy 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
Please confirm your Medicare information below.
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
TO BE COMPLETED IF WE HAVEN'T YET PROCESSED ANY MEDICARE REBATES FOR YOU.

NOTE: 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 I/We understand that consent can be withdrawn at any time.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*
Phone
This field is for validation purposes and should be left unchanged.

Consent Form

Personal Details

Your Referral or Mental Health Care Plan

Medicare Details

Bank Account Details for Medicare Rebates

Client Agreement