Page 1

23 fields

Fields on page 1

Bali – Bombings in Bali on 12 October 2002

Tsunami – Indian Ocean tsunami on

London – Bombings in London on 7 July 2005

Bali – Bombings in Bali on 1 October 2005

Dahab, Egypt – Bombings in Dahab, Egypt on

Registered person’s

person’s Medicare card number

card number

Ref no.

Mrs

Miss

Other

Family name

First given name

Registered person’s postal address

1.App PostalAdd3

Postcode

Registered person’s preferred contact phone (including area code)

Page 2

58 fields

Fields on page 2

Registered person’s email

Motor vehicle

Accommodation

Registration number

Model or make and body type

From (DD MM YYYY)

To (DD MM YYYY)

1.Motor DOTto3

To (DD MM YYYY) Name and location of medical or health care facility

Name of servicing provider

Exact number of kilometres travelled

From (DD MM YYYY)

To (DD MM YYYY)

1.Motor DOT2to3

To (DD MM YYYY) Name and location of medical or health care facility

Name of servicing provider

Exact number of kilometres travelled

1.Motor DOT31

1.Motor DOT32

1.Motor DOT33

To (DD MM YYYY)

1.Motor DOT3to3

To (DD MM YYYY) Name and location of medical or health care facility

Name of servicing provider

Exact number of kilometres travelled

Yes

Name and address of accommodation

1.Accom Add12

1.Accom Add13

Arrived (DD MM YYYY)

1.Accom Dep11

1.Accom Dep12

1.Accom Dep13

Number of persons in room

Name and address of accommodation

1.Accom Add22

1.Accom Add23

Arrived (DD MM YYYY)

Departed (DD MM YYYY)

Number of persons in room

Page 3

25 fields

Fields on page 3

Name and address of accommodation

1.Accom Add32

1.Accom Add33

1.Accom Arr31

1.Accom Arr32

1.Accom Arr33

1.Accom Dep31

1.Accom Dep32

1.Accom Dep33

Number of persons in room

Yes

Name of bank, building society or credit union

Branch number (BSB)

Account number (this may not be the card number)

Account held in the name(s) of

Claimant’s signature

Date (DD MM YYYY)

(DD MM YYYY)

YYYY)

Healthcare Federal · MS042

Disaster Health Care Assistance Scheme motor vehicle or accommodation out-of-pocket travel application (MS042)

This form is used to claim reimbursement for motor vehicle or accommodation travel expenses related to medical treatment following specific disasters including the 2002 and 2005 Bali bombings, 2004 Indian Ocean tsunami, 2005 London bombings, and 2006 Dahab Egypt bombings.

Issued by: Services Australia
Form number: MS042
Jurisdiction: Federal
Length: 3 pages

When do you need this form?

You need this form if you were affected by one of the specified disasters (Bali bombings, Indian Ocean tsunami, London bombings, or Dahab bombings) and are registered with the Disaster Health Care Assistance Scheme. You must have incurred out-of-pocket motor vehicle or accommodation expenses while traveling to receive medical or health care treatment related to your disaster-related injuries or conditions.

What you'll need

Your Medicare card number and personal details
Motor vehicle registration number and make/model details
Travel dates and exact kilometres travelled for each trip
Names and locations of medical facilities and servicing providers
Accommodation details and dates (if applicable)
Copies of receipts for expenses incurred

Where to send it

Submit the completed form and supporting documents by email to disasterhealthcare@servicesaustralia.gov.au, by post to Services Australia Disaster Health Care Assistance Scheme GPO Box 9822 Perth WA 6848, or in person at a Services Australia service centre.

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