Receipt For Health Fund Rebate

RECEIPT
Date*

DayMonthYear
Date
Practitioner name: Jurgen Van Ark

CMASA 12356

Sea Side Thai Massage
Shop 3 28 McKeon St, Maroubra NSW 2035

Phone: 02 93444014
Customer Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Type of Treatment *
Item number*
Health Fund *
Medibank Private / Bupa provider number / Other*
Supply the provider number
Amount*
Customer Address

CityState / Province

Postal / Zip Code
Health Fund Notice:
This receipt confirms payment for services rendered.
Acceptance of this receipt and payment of any rebate is determined solely by your health fund.
Sea Side Thai Massage is not responsible for declined, reduced, or rejected claims, including where a provider is not recognised by the fund.
Should be Empty:

RECEIPT