Fillable Printable Bank Account Details Collection
Fillable Printable Bank Account Details Collection
Bank Account Details Collection
1579a.1210
1 of 1
Purpose of this form
Use this form to register and store your bank account details with Medicare.
We will use these details for all Medicare payments where you are the
claimant (the person who paid for the service). Other people listed on your
Medicare card (aged 14 years and over) can use this form when consenting
to use your bank account for their Medicare payments, where they are the
claimant.
For more information or other options to register your bank account details:
• go to humanservices.gov.au/online
• call 132 011 (Note: Call charges apply – calls from mobile phones
may be charged at a higher rate)
• visit your local Medicare Service Centre.
Filling in this form
Please use black or blue pen. Print in BLOCK LETTERS.
Mark boxes like this with a ✓ or 7
Returning your form
Send the completed form to:
Department of Human Services
GPO Box 9822
in your capital city
or place in the drop box at your local Medicare Service Centre.
Privacy notice
Your personal information is protected by law, including the
Privacy Act 1988, and is collected for a Social Security, Family Assistance,
Medicare, Child Support and CRS purpose, depending on the service or
payment concerned.
This information may be required by law or collected voluntarily when you
apply for services or payments. Your information is used for the assessment
and administration of payments and services and may also be used within
Human Services, or disclosed to other parties or agencies, where you have
provided consent or it is required or authorised by law.
You can get more information about privacy by going to our website
humanservices.gov.au/privacy or requesting a copy of the full privacy policy
at one of our Service Centres.
Your details
1 Medicare card number
Ref no.
2 Dr Mr Mrs Miss Ms Other
Family name
First given name
3 Date of birth
/ /
4 Postal address
Postcode
5 Daytime phone number
Email
@
Bank account details
6 Medicare benefits cannot be paid via Electronic Funds Transfer (EFT)
if the nominated account has restrictions on EFT deposits, is a credit
card, or an overseas account.
We cannot record bank account details for children under 14 years
of age.
Name of bank, building society or credit union
Branch where your account is held
Branch number (BSB)
Account number (this may not be your card number)
Account held in the name(s) of
Consent to nominate bank account
7 Only complete this section if other people listed on your Medicare card
(aged 14 years and over) agree to use your bank account for their
Medicare payments, where they are the claimant (the person who paid
for the service).
Full name of person 1
Medicare card reference number
Signature of person 1
Date
-
/ /
Full name of person 2
Medicare card reference number
Signature of person 2
Date
-
/ /
If there are more than 2 other people, attach a separate sheet
with their details and signatures.
Medicare card holder’s declaration
8 I declare that:
• I will inform the Australian Government Department of Human
Services without delay of changes to my bank account details
• the information in this form and any attached sheets is complete
and correct.
Signature
-
Date
/ /
Bank Account Details
Collection
