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Get AU DB018 2021-2024

Application for bulk bill claim adjustment Purpose of this form Provider details Use this form when applying for a bulk bill claim adjustment for assigned Medicare benefits where the original date of service is less than 2 years old. Provider s full name 10 Reason s for bulk bill claim adjustment If you need more space attach a separate sheet with details. Privacy notice 12 Your personal information is protected by law including the Privacy Act 1988 and is collected by the Australian Government administration of payments and services. This information is required to process your application or claim. Your information may be used by the department or given to other parties for the purposes of research investigation or where you have agreed or it is required or authorised by law. Number of Assignment of benefit form s included with this application 8 Name of health professional DB018. 1411 1 of 2 Reason for bulk bill claim adjustment Declaration 13 I claim Medicare benefits for the professional services the Give details why the bulk bill incentive or Patient Episode Initiation PEI item s were omitted from the original claim or why the correct item number s or other claim details were not originally claimed. A reason why the Australian Government Department of Human Services should process the adjustment s must also be included. services specified in the attached Assignment forms. 1 Dr Mr Family name For more information Mrs Miss Ms Other First given name website humanservices. gov*au/healthprofessionals or call 132 150 Monday to Friday between 8. 30 am and 5. 00 pm Australian Eastern Standard Time. Note Call charges apply calls from mobile phones may be charged at a higher rate. www. 2 Practice address Postcode Filling in this form Postal address if different to above Please use black or blue pen Print in BLOCK LETTERS Mark boxes like this with a or 7 3 Provider number Returning your form Check that you have answered all the questions you need to answer and that you have signed and dated this form* 4 Location ID/Minor ID Send the completed form together with the required documents to Department of Human Services Medicare Bulk Bill Team GPO Box 9822 In your capital city 5 Original claim number/Easyclaim transaction ID Indicate adjustment type 6 Original date of claim Omitted bulk bill incentive or Patient Episode Initiation PEI item s original claim less than 2 years from date of service / 7 Services provided A printed copy of a spreadsheet must be included outlining patient details e*g* full name Medicare card number and reference number original date of service servicing and payee provider details and item number s to be paid* In-hospital Out-of-hospital You must indicate the type of services provided on the Assignment of benefit forms - claims for in-hospital and separately. Adjustment to previously paid claim s original claim less You must attach a new Assignment of benefit form signed by the patient for any adjustment to previously paid claim s.

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