Privacy Notice:
Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services.
This information is required to process your application or claim. Failure to provide this information to the Department of Human Services may prevent you from receiving a Medicare benefit or accessing associated services, such as bulk billing.
Your information may be used by the department or given to other parties for the purposes of research, investigation or where you have agreed or it is required or authorised by law.
You can get more information about the way in which the Department of Human Services will manage your personal information and respond to privacy complaints (including our privacy policy) at humanservices.gov.au/privacy, or by requesting a copy from the department.
I assign my right to benefits to the Practitioner who rendered the service/s or I offer to assign my right to benefits to the approved Pathology Practitioner who will render the requested pathology service/s.
Patient signature, where the patient is unable to sign the assignment of benefit form, the signature of the patient's parent, guardian or other responsible person (other than the doctor, doctor's staff, hospital proprietor, hospital staff, residential aged care facility proprietor or residential aged care facility staff) is acceptable.
The date on which the assignment of benefit was signed should be included.
