Registration Form	
MyMedicare is a voluntary patient registration model. It aims to formalise the relationship between 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 more of the care patients need, improving health outcomes.
Your completed MyMedicare Registration Form should be provided to your preferred General Practice to complete your registration process.
 
Patient Details
Family name
 <<Patient Demographics:Surname>>	
First given name 				                       Second given name
 <<Patient Demographics:First Name>>	 	<<Patient Demographics:Middle Name>>	
Date of Birth 				 
<<Patient Demographics:DOB>> 	 	
Medicare Number or DVA File Number                            Medicare IRN 
  <<Patient Demographics:Medicare Number>> or <<Patient Demographics:DVA Number>>		
Practice and Provider Details
Practice Name and Practice Address
 <<Practice/Location:Name>>	
 <<Practice/Location:Address>>	
 
Name of preferred GP____________________<<Doctor:Name>>______________________

By signing this form I agree to the following:
1.	I understand that registering in MyMedicare is voluntary.
2.	I consider this Practice to be my regular primary health care provider.
3.	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 By submitting this form, any existing registration in MyMedicare will be withdrawn, and my previous Practice and provider will automatically be notified that I am no longer registered with them under MyMedicare.
4.	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.
5.	I understand that there is no cost to register in MyMedicare.
6.	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). 

 

Full name of individual providing consent (patient, patient’s guardian/attorney or parent if required)
<<Patient Demographics:Full Name>>	
Signature	Date
<<Miscellaneous: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.
7.	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.

Office use only
Provider Number of preferred GP_____________<<Doctor:Provider Number>>_______
Please select a box to confirm the patient’s eligibility
☐ The patient has had at least 2 face-to-face consultations at the Practice in the previous 24 months
☐ The patient meets the reduced eligibility criteria of at least one face-to-face consultation at the Practice in the 
previous 24 months and the Practice is located in MMM6-7
The patient meets one of the exemption criteria:
☐ Children under 18 years whose parent is already registered at this practice󠄀
☐ Parents of a child under 18 years who is already registered at this practice󠄀
☐ Patient is following a GP they are registered with to this practice
☐ Patient experiencing family and domestic violence
☐ Patient experiencing homelessness

The practice will retain a copy of this Registration Form in the patient’s clinical records, for compliance of record keeping obligations in accordance with Federal, State and Territory legislation applicable to their practice. 

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:
8.	Services Australia privacy policy at: www.servicesaustralia.gov.au/privacy 
9.	Department of Health and Aged Care privacy policy at: https://www.health.gov.au/resources/publications/privacy-policy
10.	Australian Digital Health Agency privacy policy at: https://www.myhealthrecord.gov.au/about/privacy-policy, and
11.	Department of Veterans’ Affairs privacy policy at: https://www.dva.gov.au/privacy-policy.