MyMedicare Registration Form (Updated 6 April 2024)

MyMedicare Registration Form
MyMedicare is a voluntary patient registration model. MyMedicare aims to formalise the relationshipbetween patients, their general practice, general practitioner (GP) and primary care teams.

MyMedicare patients and their usual GP and practice will have access to new benefits to help deliver moreof the care patients need, improving health outcomes.

Your completed MyMedicare Registration Form should be provided to your preferred general practice tocomplete your registration process
Patient Details
First given name*
Second given name
Family name*
Date of birth (day)*
Date of birth (month)*
Date of birth (year)*
Medicare Number or DVA File Number*
Medicare Individual Reference Number (IRN) - the number before your name
Practice Name *
Name of preferred GP*
By signing this form I agree to the following:

I understand that registering in MyMedicare is voluntary.

1. I consider this Practice to be my regular primary health care provider.

2. I understand that I can only be registered with one Practice at a time. By submitting this form, any existing registration in MyMedicare will be withdrawn, and my previous Practice and provider will automatically be notified that I am no longer registered with them under MyMedicare.

3. I understand that I will remain registered unless:
• I register with a different Practice.
• I request my GP/Practice or Services Australia to withdraw my registration.
• My GP or Practice decides to withdraw my registration.

4. I understand that there is no cost to register in MyMedicare.

5. I declare I have read and understand the MyMedicare Privacy Notice and consent to my personal information being collected, used and disclosed by the relevant agencies such as Services Australia, the Department of Health and
Aged Care, the Australian Digital Health Agency and, where applicable, the Department of Veterans’ Affairs as specified in the MyMedicare Privacy Notice (a link to this notice is provided in the Privacy Statement at the bottom of this
form).

6. I understand that I can register for MyMedicare even if the information requested in the ‘About You’ section of this form is not provided.
Full name of individual providing consent (patient, patient’s guardian/attorney or parent if required)*
Signature*

Clear
Date*

DayMonthYear
Date
If a parent or guardian has completed this form on behalf of a patient aged 14-17, please confirm the patient is aware of this registration and provided informed consent.

Yes
Consent for MyMedicare registration for patients under 14 years of age must be provided by the patient’s parent or legal guardian.

Patients aged 14-17 years must provide their consent to register for MyMedicare.
- A parent or guardian of a patient aged 14-17 years may complete the Registration Form if the 14-17 year old is aware of the registration and has provided their consent for this person to act on their behalf.
For a patient 14 years or older, who lacks capacity to make decisions for themselves, consent for the MyMedicare registration will need to be provided by an individual who is authorised to act on the patient’s behalf.
About you
The information you provide will help your practice and the government to plan and improve your health care services. We will share this information with your MyMedicare practice. If you choose not to provide this information as part of your registration, you will still be able to register for MyMedicare. You may still provide this additional information about you directly to your practice.

We may already have your information if you have registered in the past.
1. Are you of Aboriginal or Torres Strait Islander descent?

NoYes - Aboriginal AustralianYes - Torres Strait Islander AustralianBoth Aboriginal and Torres Strait Islander AustralianPrefer not to answer
2. In which country were you born?

AustraliaEnglandNew ZealandIndiaPhilippinesVietnamItalySouth AfricaMalaysiaScotlandOther (please specify)Prefer not to answer
2. Other - please specify in which country were you born
3. What is the main language you speak at home?

English onlyMandarinArabicCantoneseVietnameseItalianGreekHindiSpanishPunjabiOther (please specify)Prefer not to answer
3. Other - please specify the main language you speak at home
4. How well do you speak English?

Very wellWellNot wellNot at allPrefer not to answer
5. How do you describe your gender?

Man or maleWoman or femaleNon-binaryI use a different termPrefer not to answer
^ Gender refers to current gender, which may be different to sex recorded at birth and may be different to what is indicated on legal documents.
6. How do you describe your sexual orientation? Only complete this question if you are aged 15 years or over.

Straight (heterosexual)Gay or lesbianBisexualI use a different termDon’t knowPrefer not to answer
7A. In everyday life, do you have difficulty participating in any of the following, related to a long-term health condition or disability?

YesNoPrefer not to answer
7A. Daily activities such as:
- washing, dressing
- walking, handling or lifting objects
- speaking, using communication devices
7B. In everyday life, do you have difficulty participating in any of the following, related to a long-term health condition or disability?

YesNoPrefer not to answer
7B. Activities of independent living, such as:
- shopping, cooking, caring for others
- making decisions, handling stress
- learning, solving problems
- relationships with people
7C. Activities of work, education and community living,such as:

YesNoPrefer not to answer
7C. Activities of work, education and community living, such as:
- social and community life
- work, education or training
8. The categories below are disability groups based on underlying health conditions and or impairments, activity limitations and participation restrictions. Which of the following best describes your health condition or disability? (Please tick the box next to any that apply – you can select more than one box)

Sensory (e.g., sight, hearing, speech)Intellectual (e.g., difficulty learning or understanding)Physical (e.g., breathing difficulties, chronic orrecurrent pain, blackouts or seizures, incomplete use of limbs)Psychosocial (e.g., nervous or emotional conditions, social or behavioural difficulties)Head injury, stroke or acquired brain injuryOtherPrefer not to answer
8. Other
Privacy Statement
The law regulates how Services Australia, the Department of Health and Aged Care, the Australian Digital Health Agency and the Department of Veterans’ Affairs may handle your personal information. Services Australia is collecting your personal information to assess your eligibility for MyMedicare and provide services to you and payments linked to your provider as a result of your MyMedicare registration.

Your information will only be shared with relevant government agencies such as the Department of Health and Aged Care, Australian Digital Health Agency and the Department of Veterans’ Affairs, where you have agreed, or where the law allows or requires it. The MyMedicare Privacy Notice describes how your information will be managed consistent with our obligations under the Privacy Act 1988 and the Australian Privacy Principles.

The notice can be found at https://www.health.gov.au/resources/publications/mymedicare-privacy-notice

You can also read the:
- Services Australia privacy policy at: www.servicesaustralia.gov.au/privacy
- Department of Health and Aged Care privacy policy at: https://www.health.gov.au/resources/publications/privacy-policy
- Australian Digital Health Agency privacy policy at: https://www.myhealthrecord.gov.au/about/privacy-policy, and
- Department of Veterans’ Affairs privacy policy at: https://www.dva.gov.au/privacy-policy.
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MyMedicare Registration Form

Patient Details

About you

Privacy Statement