Medicare Claim Form

Medicare Claim Form
Patient's Details
The patient is the person who received the medical service.
Patient's Name*
First NameLast Name
Claimant’s Details
The claimant is the person who paid for or is likely to pay for the medical and/or dental expenses. Benefits will be paid to this person.
Claimant's Name*
First NameLast Name
Date of Birth
MonthDayYear
Date
Gender
MaleFemale
Business Name
For non-compensation claims if the claimant is an organisation/business that has incurred the expenses on behalf of the patient
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Area CodePhone Number
Email
example@example.com
Service Details
The medical services you are claiming benefit for*
Ref no. Patient's Name Services provided by Account paid in full?
1
2
3
Was the patient an in-patient of a hospital or approved day facility?
YesNo
Date of admission
MonthDayYear
Date
Date of discharge
MonthDayYear
Date
Claimant’s Declaration
I hereby claim benefits for the professional services to which this claim relates and I declare that:
- Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua.
- Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat.
- Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur.
Claimant's Signature*
Clear
Should be Empty: