MyMedicare Registration Form - Diamond Creek Medical Centre

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Patient Information

Name*

Date of Birth*

Medicare Number

Reference Number

Medicare Card Expiry Date

DVA Gold / White

DVA Expiry Date

Pension/HCC Number

Expiry Date

Practice Information

Diamond Creek Medical Centre: 82 Main Hurstbridge Road, Diamond Creek Vic. 3089

Patient Declaration

By signing this form I agree to the following:

I understand that registering in MyMedicare is voluntary.
I consider this Practice to be my regular primary health care provider.
I understand that I can only be registered with one Practice at a time. By submitting this form, any existing registration in MyMedicare will be withdrawn, and my previous Practice and provider will automatically be notified that I am no longer registered with them under MyMedicare.
- I register with a different Practice.
- I request my GP/Practice or Services Australia to withdraw my registration.
- My GP or Practice decides to withdraw my registration.
I understand that there is no cost to register in MyMedicare.
I declare I have read and understand the MyMedicare Privacy Notice and consent to my personal information being collected, used and disclosed by the relevant agencies such as Services Australia, the Department of Health and Aged Care, the Australian Digital Health Agency and, where applicable, the Department of Veterans’ Affairs as specified in the MyMedicare Privacy Notice (a link to this notice is provided in the Privacy Statement at the bottom of this form).

Full name of individual providing consent (patient, patient’s guardian/attorney or parent if required)

Signature*

Todays Date

If a parent or guardian has completed this form on behalf of a patient aged 14-17, please confirm the patient is aware of this registration and provided informed consent.

Consent for MyMedicare registration for patients under 14 years of age must be provided by the patient’s parent or legal guardian.

Patients aged 14-17 years must provide their consent to register for MyMedicare. A parent or guardian of a patient aged 14-17 years may complete the Registration Form if the 14-17 year old is aware of the registration and has provided their consent for this person to act on their behalf.

For a patient 14 years or older, who lacks capacity to make decisions for themselves, consent for the MyMedicare registration will need to be provided by an individual who is authorised to act on the patient’s behalf.

Yes, I consent

Privacy Statement The law regulates how Services Australia, the Department of Health and Aged Care, the Australian Digital Health Agency and the Department of Veterans’ Affairs may handle your personal information. Services Australia is collecting your personal information to assess your eligibility for MyMedicare and provide services to you and payments linked to your provider as a result of your MyMedicare registration. Your information will only be shared with relevant government agencies such as the Department of Health and Aged Care, Australian Digital Health Agency and the Department of Veterans’ Affairs, where you have agreed, or where the law allows or requires it. The MyMedicare Privacy Notice describes how your information will be managed consistent with our obligations under the Privacy Act 1988 and the Australian Privacy Principles.

The notice can be found at https://www.health.gov.au/resources/publications/mymedicare-privacy-notice

You can also read the:

Services Australia privacy policy at: www.servicesaustralia.gov.au/privacy
Department of Health and Aged Care privacy policy at:https://www.health.gov.au/resources/publications/privacy-policy
Australian Digital Health Agency privacy policy at:https://www.myhealthrecord.gov.au/about/privacy-policy, and
Department of Veterans’ Affairs privacy policy at: https://www.dva.gov.au/privacy-policy

Name

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Patient Information

Practice Information

Patient Declaration

Privacy Policy