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Get AU MediGap NIB0056 2009-2024

BATCH HEADER OR ACCOUNT FORM Instructions Complete parts 1 and 4 if attaching your own accounts. Your accounts much include all information in parts 2 and 3 PART 1 - BATCH DETAILS Provider s name Total value of claims in batch Number of Date lodged PART 2 - ACCOUNT DETAILS nib customer number Patient s name Customer s name if not the same as the Patient Patient s date of birth Hospital provider number Hospital name Your reference Referral details Referral date Total charge Referral period 3 months 12 months Indefinite Referring doctor s Referring doctor s name PART 3 - SERVICE DETAILS MBS Item no. abn 83 000 124 381 nib MediGap Department Reply Paid 62208 NEWCASTLE NSW 2300 Phone 1300 853 530 option 1 Fax 02 4925 1906 Email medigap nib. com*au Web providers. nib. com*au This medical practice agrees to bill nib MediGap directly for the services on this account and accepts the terms of MediGap as set out in the current Products Procedures Guide. The patient/nib customer has been advised of the payment arrangements for the services on this account and no further payment is required* nib MediGap is a NO GAP scheme. Please ensure correct Medicare and Reference No s are stated Patient reference no. Medicare no. Description of service Service conditions - tick below if applies to each service of Date Service Full cost Part of a multiple procedure Referred within a Designated Considered Performed not normal not for on separate after care comparison sites Self determined Assisting Assisting doctor s Surgeon s name Surgeon s PART 4 - AUTHORISATION Are the services on this claim related to compensation Yes No Does your practice have financial interests in any hospital or health insurance product Has the patient/nib customer been provided with informed financial consent Declaration The professional services on the attached account were provided by or on behalf of a doctor in this practice and were rendered to a private in-patient of a hospital or registered day hospital facility. I declare that the charges above are full cost for services provided and that no additional charges have been placed on the customer for those services. Signature of authorised person For assistance or more information please call the MEDIGAP HOTLINE 1300 853 530 option 1 nib00560809. abn 83 000 124 381 nib MediGap Department Reply Paid 62208 NEWCASTLE NSW 2300 Phone 1300 853 530 option 1 Fax 02 4925 1906 Email medigap nib. com*au Web providers. nib. com*au This medical practice agrees to bill nib MediGap directly for the services on this account and accepts the terms of MediGap as set out in the current Products Procedures Guide. com*au Web providers. nib. com*au This medical practice agrees to bill nib MediGap directly for the services on this account and accepts the terms of MediGap as set out in the current Products Procedures Guide. The patient/nib customer has been advised of the payment arrangements for the services on this account and no further payment is required* nib MediGap is a NO GAP scheme. .

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