Get AU DB2-DB

If completing by hand please use BLACK PEN INITIAL FIRST NAME P A T I E N ASSIGNMENT FORM ITEM NO. SURNAME This form is the approved form as prescribed under section 12 2 of the Dental Benefits Act 2008 DESCRIPTION OF SERVICE optional DB2-DB BENEFIT ASSIGNED RESIDENTIAL ADDRESS DATE OF BIRTH DD / MM / YYYY MEDICARE NUMBER PATIENT REF. No. EXPIRY DATE CHECKED X DATE OF SERVICE Medicare copy D L S I assign my right to benefits to the dental provider who has rendered the service s. If completing by hand please use BLACK PEN INITIAL FIRST NAME P A T I E N ASSIGNMENT FORM ITEM NO. SURNAME This form is the approved form as prescribed under section 12 2 of the Dental Benefits Act 2008 DESCRIPTION OF SERVICE optional DB2-DB BENEFIT ASSIGNED RESIDENTIAL ADDRESS DATE OF BIRTH DD / MM / YYYY MEDICARE NUMBER PATIENT REF* No* EXPIRY DATE CHECKED X DATE OF SERVICE Medicare copy D L S I assign my right to benefits to the dental provider who has rendered the service s. Patient unable to sign - Dental provider who rendered the above service s SIGNATURE OF PATIENT / DATE Provider number Name DB2-DB a. 1405 Save Reset Print Practitioner copy PATIENT HAS SIGNED MEDICARE COPY Privacy and your personal information Your personal information is protected by law including the Privacy Act 1988 and is collected by the Australian Government Department of Human Services for the assessment and 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. You can get more information about the way in which the Department of Human Services will manage your personal information including our privacy policy at humanservices. SURNAME This form is the approved form as prescribed under section 12 2 of the Dental Benefits Act 2008 DESCRIPTION OF SERVICE optional DB2-DB BENEFIT ASSIGNED RESIDENTIAL ADDRESS DATE OF BIRTH DD / MM / YYYY MEDICARE NUMBER PATIENT REF* No* EXPIRY DATE CHECKED X DATE OF SERVICE Medicare copy D L S I assign my right to benefits to the dental provider who has rendered the service s. Patient unable to sign - Dental provider who rendered the above service s SIGNATURE OF PATIENT / DATE Provider number Name DB2-DB a. Patient unable to sign - Dental provider who rendered the above service s SIGNATURE OF PATIENT / DATE Provider number Name DB2-DB a. 1405 Save Reset Print Practitioner copy PATIENT HAS SIGNED MEDICARE COPY Privacy and your personal information Your personal information is protected by law including the Privacy Act 1988 and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. 1405 Save Reset Print Practitioner copy PATIENT HAS SIGNED MEDICARE COPY Privacy and your personal information Your personal information is protected by law including the Privacy Act 1988 and is collected by the Australian Government Department of Human Services for the assessment and 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. .