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.

Patient details

Family Name *

First given name *

Second given name

Date of Birth *

Medicare of DVA File Number *

Medicare IRN

Practice and Provider Details

Practice Name and Practice Address

Next Practice Deakin

2/4 Makin Place, Deakin ACT 2600

02 6185 5555

Name of preferred GP *

By signing this form I agree to the following:

I understand that registering in MyMedicare is voluntary.
I consider this Practice to be my regular primary health care provider.
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 By submitting this form, any existing registration in MyMedicare will be withdrawn, and my previous Practice and provider will automatically be notified that I am no longer registered with them under MyMedicare.
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.
I understand that there is no cost to register in MyMedicare.
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) *

Signature *

Clear

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.

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.

Registration Form

Patient details

Practice and Provider Details

Practice Name and Practice Address

Privacy Statement