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
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