MyMedicare Registration Form
MyMedicare is a voluntary patient registration model. MyMedicare 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.
Sign in to Google to save your progress. Learn more
Patient details
Family name *
First given name *
Second given name
Date of birth *
MM
/
DD
/
YYYY
Medicare number or DVA file number *
Medicare IRN
Practice and provider details
Practice name
Practice address
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 By submitting this form, any existing registration in MyMedicare will be withdrawn, and my previous practice and provider will automatically be notified that I am no longer registered with them under MyMedicare.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.

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 — type your full name as your electronic signature *
Date *
MM
/
DD
/
YYYY
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 patients under 14 must be provided by the parent or legal guardian. Patients aged 14-17 years must provide their consent to register.
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms