Page 2

26 fields

Fields on page 2

transfer to a new card

copy to a new card

transfer to an existing card

copy to an existing card

Medicare card number

card number person 1

card

Ref no.

Mrs

Miss

Other

Family name

First given name

Second given name

Yes

Give details of your previous name

Date of birth (DD

of birth (DD MM YYYY)

(DD MM YYYY)

Male

Female

Non-binary

Page 3

54 fields

Fields on page 3

Postal address

1.App1 PostalAdd3

Postcode

Contact phone number (including area code) to be person 1 is 15 years or older

Email to be completed if person 1 is 15 years or older

Yes – Aboriginal Australian

Yes – Torres Strait Islander Australian

Yes

transfer to a new card with person 1

copy to a new card with person 1

transfer to a new card

copy to a new card

transfer to an existing card

copy to an existing card

Medicare card number

card number person 2

card

Ref no.

Mrs

Miss

Other

Family name

First given name

Second given name

Date of birth (DD

of birth (DD MM YYYY)

(DD MM YYYY)

Male

Female

Non-binary

Yes – Aboriginal Australian

Yes – Torres Strait Islander Australian

Yes

Your full name

transfer to a new card with person 1

Date (DD MM YYYY)

(DD MM YYYY)

YYYY)

Yes

Page 4

58 fields

Fields on page 4

transfer to a new card with person 1

copy to a new card with person 1

transfer to a new card

copy to a new card

transfer to an existing card

copy to an existing card

Medicare card number

card number person 3

card

Ref no.

Mrs

Miss

Other

Dr Mr Mrs Miss Ms Mx Other

First given name

Second given name

Date of birth (DD

of birth (DD MM YYYY)

(DD MM YYYY)

Male

Female

Non-binary

Yes – Aboriginal Australian

Yes – Torres Strait Islander Australian

Yes

Your full name

1.App3 Declaration

Date (DD MM YYYY)

(DD MM YYYY)

YYYY)

Yes

Medicare card number

card number

1.Existing MCN 3

1.Existing MCN 4

Mrs

Miss

Ref no.

Family name

First given name

Second given name

Date of birth (DD

of birth (DD MM YYYY)

(DD MM YYYY)

Male

Female

Non-binary

Page 5

30 fields

Fields on page 5

Postal address

1.Existing PostalAdd3

Postcode

Contact phone number (including area code)

Yes – Aboriginal Australian

Yes – Torres Strait Islander Australian

Yes

Your full name

1.Existing PrivacyDec

Date (DD MM YYYY)

(DD MM YYYY)

YYYY)

Yes

Your relationship to the child(ren) younger than 15 years (for example, grandparent)

Full name of parent or guardian 1

1.PG1 Declaration

Date (DD MM YYYY)

(DD MM YYYY)

YYYY)

Full name of parent or guardian 2

1.PG2 Declaration

Date (DD MM YYYY)

(DD MM YYYY)

YYYY)

Page 6

15 fields

Fields on page 6

Name of bank, building society or credit union (Australian financial institutions only)

Branch number (BSB)

Account number (this may not be the card number)

Account held in the name(s) of

Full name of person 1

1.Dec1 Declaration

Date (DD MM YYYY)

(DD MM YYYY)

YYYY)

Full name of parent, guardian or primary carer

1.PG Declaration

Date (DD MM YYYY)

(DD MM YYYY)

YYYY)

Healthcare Federal · MS011

Medicare Card Application (MS011)

This form is used to transfer or copy yourself or family members to a new or existing Medicare card.

Issued by: Services Australia
Form number: MS011
Jurisdiction: Federal
Length: 6 pages

When do you need this form?

You need this form when you want to get your own Medicare card (like a child over 15 wanting their own card), add someone to an existing Medicare card, or move between Medicare cards. This commonly happens when children become independent, couples want to share a card, or family arrangements change.

What you'll need

Valid identification (Australian passport, birth certificate, citizenship certificate, driver licence, or ImmiCard)
Proof of parental responsibility if applying for a child under 15 not previously enrolled with you
Current bank account details for Medicare benefit payments
Details of the existing Medicare card if copying or transferring to one

Where to send it

Submit the completed form to Services Australia through their website, in person at a service centre, or by post to the address specified on the form.

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