MyMedicare

Patient 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.

This registration form has been adapted by HFGP and contains the same information as the Australian Government registration form.

For more information on MyMedicare please see the MyMedicare website or the Hills Family General Practice website.

Please complete one of these forms for every individual you wish to register.

You are eligible to register if you have been to our practice twice sometime in the last 2 years. Parents/guardians and children can be registered if one of them is eligible and registered. For further details please see the MyMedicare website.

PATIENT DETAILS

First Name

Last Name

Date of Birth

Gender

MaleFemale

Medicare Card Number *

Medicare Card IRN Number *

Name of Preferred General Practice *Thank you for choosing HFGP

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 By submitting this form, any existing registration in MyMedicare will be withdrawn, and my previous Practice and provider will automatically be notified that I am no longer registered with them under MyMedicare.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) .
I understand that I can register for MyMedicare even if the information requested in the ‘About You’ section of this form is not provided.

Signature of Patient (or Guardian) *

Draw signature|Type signatureClear

Date signed *

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 cosent 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.

The following ABOUT YOU section is completely optional. Please complete this ection if you wish, read the below information and press SUMBIT at the bottom of this page. HFGP will then confirm your eligibility and complete the registration process for you in MyMedicare.

ABOUT YOU (Optional)

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?

2. In which country were you born?

If you answered other, please specify

3.What is the main language you speak at home?

If you answered other, please specify

4.How well do you speak English?

5.How do you describe your gender? 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. Please select one box

6.How do you describe your sexual orientation? Only complete this question if you are aged 15 years or over

7. In every day life, do you have difficulty participating in any of the following, related to a long-term health condition or disability?

A. Daily activities such as washing, dressing, walking, handling or lifting objects, speaking, using communication devices?

B. Activities of independent living such as shopping, cooking, caring for others, making decisions, handling stress, learning, solving problems, relationships with people

C. Activities of work, education, and community living, such as social and community life, work, education, or training ?

8. If you answered yes to above, the categories below are disability groups based on underlying health conditions or impairments, activity limitations and participation restrictions. Which of the following best describes your health condition or disability? (You can select more than one)

Sensory (e.g., sight, hearing, speech)Intellectual (e.g., difficulty learning or understanding) Physical (e.g., breathing difficulties, chronic or recurrent 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 injury OtherPrefer not answer

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 MyMedicare – PrivacyNotice.

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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