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Get Request For Reimbursement Form

Request for reimbursement and authorisation 6 Family name For more information If you need assistance completing this form or need more information call 1800 700 270 call charges apply from mobile phones and select option 4 between 8. 30 am to 5. 00 pm Australian Eastern Standard time Monday to Friday or go to humanservices. gov*au/healthprofessionals and search for First given name 7 Name of medical practice Returning your form s 8 Practice address Send the completed form to Department of Human Services Prior written approval of specialised drugs Reply Paid 9826 Hobart TAS 7001 or fax to 1300 154 190 Print in BLOCK LETTERS Tick where applicable Postcode 9 Work phone number Centrelink Medicare Australia Child Support and CRS Australia are all part of the Australian Government Department of Human Services. Personal information held by Human Services is protected by law including the Privacy Act 1988. The information provided on this form will be used to assess eligibility of a nominated person to receive PBS subsidised treatment. The collection of this information is authorised by the National Health Act 1953. This information may be disclosed to the Department of Health and Ageing Department of Veterans Affairs or as authorised or required by law. Patient s details 1 Medicare/DVA card number Miss Conditions and treatment details / / 10 Date of treatment 11 Declare the number of units used against the condition* Specify the number of vials remaining on hand. 100 units 300 units 500 units Right Left Right Left Right Left Mrs Fax number Privacy notice 2 Mr Ms blepharospasm or hemifacial spasm in adults only Ref no. dynamic equinus foot deformity Other spasmodic torticollis 3 Date of birth upper limb spasticity stroke / axillary hyperhidrosis spasm in patients 12 years Patient s declaration 4 I declare that the patient named above is receiving medical treatment with Full name of parent or authorised person cerebral palsy not eligible Number of vials on hand Provider s declaration the information provided on this form is correct. Provider s signature Provider s details - 5 Provider number not applicable Initial patients are required to complete the appropriate acknowledgement form available on the Medicare Australia website Patient s signature or parent s signature for patients two to 17 years of age or authorised person on behalf of patient Signature Date Page 1 of 1 4053. 30 am to 5. 00 pm Australian Eastern Standard time Monday to Friday or go to humanservices. gov*au/healthprofessionals and search for First given name 7 Name of medical practice Returning your form s 8 Practice address Send the completed form to Department of Human Services Prior written approval of specialised drugs Reply Paid 9826 Hobart TAS 7001 or fax to 1300 154 190 Print in BLOCK LETTERS Tick where applicable Postcode 9 Work phone number Centrelink Medicare Australia Child Support and CRS Australia are all part of the Australian Government Department of Human Services. Personal information held by Human Services is protected by law including the Privacy Act 1988. The information provided on this form will be used to assess eligibility of a nominated person to receive PBS subsidised treatment.

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