Billing Details Billing Details Do You hold a Medicare Card?* —Please choose an option—YesNo Expiry Date (DD/MM/YYYY)* Medicare Number* Ref #* *Note: The reference number is on the far LEFT of each name on the card Is this a work cover claim?* —Please choose an option—YesNo Do You hold a DVA Card?* —Please choose an option—YesNo Expiry Date (DD/MM/YYYY)* Reference Number* Colour*—Please choose an option—WhiteGoldOrange Do You have Health Insurance?* —Please choose an option—YesNo Name of health fund* Commencement Date (DD/MM/YYYY)* Membership Number* Does your insurance cover hospital? —Please choose an option—YesNo Does your insurance cover dental? —Please choose an option—YesNo Have you held this level of cover for 12 months or more? —Please choose an option—YesNo Are there any excesses, restrictions or exclusions on this policy?* —Please choose an option—YesNo Please List NOTE: This information is needed at your consultation and can be obtained in advance from your health fund ----------------------------------------------------
