A Division of MDR Computer Services Pty Ltd
Patient Medicare OnLine Claim
Enter Invoice Number
Patient Details
  Patient Name
Medicare Details 
  Medicare No
  Card Position
Private Health Insurance Details
  Private Health Fund
  Policy Number
Service Provider
  Service Provider
  Provider No
Claimant's Declaration

I hereby claim benefits for the professional services to which this claim relates and

I declare that:

• I have paid for, or am liable to pay, the expenses for these services

• the services were not for the purpose of life insurance, superannuation or provident account schemes,

  admission to a friendly society, health screening, mass immunisation, or connected with the patient’s employment

• the services were not provided by or on behalf of the Commonwealth, a state or territory or a local governing

  body or an authority established by a law of theCommonwealth, a state or territory

• to the best of my knowledge and belief all of the information in this claim is true and correct.

I understand that:

• it is an offence under the Health Insurance Act 1973 to make a false statement relating to Medicare benefits