Medicare Single Query Form

FACSIMILE
TO:
MEDICARE AUSTRALIA
FROM:
Fax 8922 6322
NAME
CLINIC
FAX
DATE:
(Tick One)
Wednesday, 19 October 2011
PHONE
 Please tell us the Medicare number for the following person.
 Please change the following person’s name. Old name ……………………………….
 The following person’s Medicare number is about to expire, please renew.
 The following person’s Medicare number expired in the last 6 months, please renew.
 The following person has 2 Medicare cards.
 Please tell us the expiry date of the following person’s Medicare card.
 The following person passed away on ………………………
 Other .......................................................................................................................................
.................................................................................................................................................
NAME
.................................................................................................................. (New name if applicable)
DOB
............/ ........... /.............
MEDICARE NUMBER
................................................................
Ref............
Valid to ......................
2nd NUMBER (if applicable) ..............................................................
Ref............
Valid to ......................
FOR BABIES ONLY – MEDICARE UNKNOWN
MOTHER’S NAME
........................................................................................................................................
MOTHER’S MEDICARE NUMBER
...............................................
CHILD’S HRN
.............................
OTHER INFORMATION WHICH MAY BE RELEVANT (eg, visitor from another community)
.............................................................................................................................................................................
Signed: .....................................................
Position: Medicare Trainer .......................................
I certify that, to the best of my knowledge, the person named on this fax is a resident of this community or is
a current client of this medical service.
Department of Health is a Smoke Free Workplace
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CASUARINA NT 0811