Fields on page 2
A newborn is a
New
New enrolment (Sections 1, 2, 3, 6, 7, 8 and 9)
Adding someone – (Sections 1, 2, 3, 6, 7, 8, and 9)
For a child in the care of someone other than a parent, provide one of the following
• Letter from parent giving permission for child(ren) to be included on the
• Centrelink documents confirming applicant is receiving benefits for the
Title: Mr
Mrs
Miss
Ms
Mx
(mandatory)
1.App FamName
Mrs Miss Ms Mx Other
1.App SecondGivName
First given name Other name(s) you are or have been known by (provide previous name here if notifying us of a name change)
new address
(if Postal different address to above)
Postal address (if different to above) Provide previous address, if known (or if you are telling us about a change of address)
(including Daytime phone area code) number
Gender: Male
Female
Non-binary
(DD Date MM of birth YYYY)
(DD Date MM of birth YYYY)
(DD Date MM of birth YYYY)
Are you of Aboriginal or Torres Strait Islander Australian descent? Yes – Aboriginal Australian
Yes – Torres Strait Islander Australian
Yes–Both
or Torres Strait Islander Australian
Islander Australian descent? Yes –
Yes – Aboriginal
– Aboriginal Australian
One of the following people can act as a referee to prove your identity: • community elder • nurse • health service manager • school principal employee with 5 or more years of continuous service • council chairperson • minister of religion • welfare organisation worker.
am providing this reference because the applicant cannot provide ID. I have known the applicant personally for
year(s)
Medical records
School records
Church records
Other
year(s) personally for
information I have provided in this form is complete and correct. giving false or misleading information is a serious offence and that I may be contacted
my statement.
statement.
1.Ref Date3
(including Daytime phone area code) number
Date (DD MM YYYY)
No
Yes
Lost
Stolen
Damaged or destroyed
Expired
Section 5
Copy to a
Medicare
Section 1
Fields on page 3
Section 6 Additional information You can write extra information to help us understand your request. For example, my child is going to boarding school and needs their own Medicare card.
1.People Card
New
Adding a new
Partner
Dependent child
Other
organisation worker.
Title: Mr
Mrs
Miss
Ms
Mx
Give details
1.People FamName
Mrs Miss Ms Mx Other
Second given name
Gender: Male
Female
Non-binary
(DD MM YYYY)
(DD MM YYYY)
given name
Date of birth Gender: Male Female Non-binary (DD MM YYYY) Other name(s) the person is or has been known by (provide previous name here if notifying us of a name change)
Is this person of Aboriginal or Torres Strait Islander Australian descent? Yes-Aboriginal Australian
Yes-Torres Strait Islander Australian
Yes–Both
(if Medicare already card enrolled) number
Strait Islander Australian descent
descent
Yes-Aboriginal
Additional person 1
Date (DD MM YYYY)
Date (DD MM YYYY)
Date (DD MM YYYY)
I (full name of referee)
am providing this reference because the above mentioned person cannot provide ID. I have known this person personally for
year(s)
Medical records
School records
Church records
Other
Give details
misleading information is a serious offence.
1.Dec Date1
1.Dec Date2
1.Dec Date3
(including area code)
Date (DD MM YYYY)
Fields on page 4
Partner
Dependent child
Other
Give details
Title: Mr
Mrs
Miss
Ms
Mx
Give details
Family name
Mrs Miss Ms Mx Other
1.OtherP SecondName
Gender: Male
Female
Non-binary
(DD Date MM of birth YYYY)
(DD Date MM of birth YYYY)
given name
Date of birth Gender: Male Female Non-binary (DD MM YYYY) Other name(s) the person is or has been known by (provide previous name here if notifying us of a name change)
Is this person of Aboriginal or Torres Strait Islander Australian descent? Yes-Aboriginal Australian
Yes-Torres Strait Islander Australian
Yes–Both
(if already enrolled)
Strait Islander Australian descent
descent
Yes-Aboriginal
Additional person 2
Date (DD MM YYYY)
Date (DD MM YYYY)
Date (DD MM YYYY)
and declaration. Only required if Additional Person 2 cannot provide ID.
am providing this reference because the above mentioned person cannot provide ID. I have known this person personally for
year(s)
Medical records
School records
Church records
Other
Give details
misleading information is a serious offence.
Date (DD MM YYYY)
Date (DD MM YYYY)
Date (DD MM YYYY)
(including area code)
Date (DD MM YYYY)
Applicant's or cardholder's
1.OtherP Date1
1.OtherP Date2
1.OtherP Date3
Fields on page 5
No
Yes
No – Do not give me a My Health Record
Yes – Give me a My Health Record
No
Yes
person is 14 years or older, they must complete the My Health Record question, read person – Name (as stated in Section 7)
read the Privacy notice and sign their declaration.
Family name
No – Do not give this person a My Health Record
Yes – Give this person a My Health Record
that: read and understood the Privacy notice in Section 8 information I have provided at question 5 is complete and correct.
1.OtherP2 Date1
1.OtherP2 Date2
1.OtherP2 Date3
No
Yes
Fields on page 6
person – Name (as stated in Section 7)
1.People SecName3
Second
No – Do not give this person a My Health Record
Yes – Give this person a My Health Record
that: read and understood the Privacy notice in Section 8 information I have provided at question 9 is complete and correct.
1.OtherP Date12
1.OtherP Date22
1.OtherP Date32
Applicant's or cardholder's
1.OtherP Date13
1.OtherP Date23
1.OtherP Date33
