Application to copy or transfer from

one Medicare card to another (MS011)

When to use this form Bank account details

Use this form if you need to: So we can make payments into your bank account, you will need to
provide your bank account details. These details will be used for
• Transfer to a new Medicare card
future electronic payments when you claim your Medicare benefit(s).
When a person transfers to a new Medicare card, they will no
longer be on the previous Medicare card. For example, a child You must tell us immediately if you change your bank account
originally enrolled on their parent’s Medicare card who is details.
15 years of age or over chooses to have their own card and no
longer be on their parent’s Medicare card. Medicare Safety Net
• Copy to a new Medicare card If your circumstances change, you will need to update your Medicare
When a person is copied to a new Medicare card, they remain Safety Net details. The Medicare Safety Net provides families and
active on both their new and existing Medicare cards. For individuals with financial assistance for high out-of-pocket expenses
example, a child who attends boarding school can have a card for out-of-hospital Medicare Benefits Schedule services. For more
of their own and still be listed on their parent’s Medicare card. information, go to servicesaustralia.gov.au/safetynet
www.

• Transfer to an existing Medicare card

When a person transfers to an existing Medicare card, they will For more information
no longer be on the previous Medicare card and will become
For more information about Medicare cards, go to
active on the card they transfer to. For example, a couple
servicesaustralia.gov.au/medicarecard or call 132 011 Monday to
chooses to be enrolled on the same Medicare card.
www.

Friday, 8:30 am to 5 pm, Australian Eastern Standard Time.

• Copy to an existing Medicare card
Call charges may apply.
When a person is copied to an existing Medicare card, they
remain active on both Medicare cards. For example, a parent or
a primary carer wants to have a child copied onto their Filling in this form
Medicare card. You can complete this form on your computer, print and sign it.
If you have a printed form:
Identification • Use black or blue pen.
Person 1 must provide identification. If person 1 is a child under • Print in BLOCK LETTERS.
15 years of age, a parent or guardian will need to provide • Where you see a box like this Go to 1 skip to the question
identification. Appropriate identification could be the original or number shown.
certified copies of a:
• birth certificate Returning this form
• current Australian driver licence, and/or Check that all required questions are answered and that the form
• current passport. is signed and dated.
Bring your completed form and original or certified documents to
Additional documents one of our Service Centres.
If you are not the parent of the child under 15 years of age, you will If you live in a remote area, you can send your application together
need to provide documents to confirm evidence of care (for example, with certified copies of documents and the reason for not being
a court order). able to attend in person, to:
Services Australia
My Health Record Medicare
If you are copying or transferring child(ren) who are registered for a GPO Box 9822
My Health Record, you should check and update the Medicare in your capital city
consent settings for your child’s My Health Record. This will let you
know who can see your child’s Medicare information.
Go to myhealthrecord.gov.au for more information.

MS011.2008 1 of 6
Details of people wanting to copy or transfer 10 Read this before answering the following question.
This question is voluntary and will not affect your application.
Person 1 If you do answer, the information will help us to continue to
1 I would like to: improve services to Aboriginal and Torres Strait Islander
Australians.
Tick one only
You can have this information removed from Medicare
transfer to a new card
records at any time by calling the Aboriginal and Torres Strait
copy to a new card Islander Access Line on 1800 556 955 or by visiting one of
transfer to an existing card our service centres.
copy to an existing card Call charges may apply.
2 Medicare card number person 1 Are you of Aboriginal or Torres Strait Islander Australian
descent?
 Ref no.
If you are of both Aboriginal and Torres Strait Islander Australian
descent, tick both ‘Yes’ boxes.
3 Mr Mrs Miss Ms Other
No
Family name
Yes – Aboriginal Australian
Yes – Torres Strait Islander Australian
First given name
11 Read this before answering the following question.
This question is voluntary and will not affect your payment.
Second given name If you do answer, the information will help us to continue to
improve services to people of Australian South Sea Islander
descent.
4 Have you ever used or been known by any other name Australian South Sea Islanders are the descendants of Pacific
(for example, name at birth, name before marriage, previous Islander labourers brought from the Western Pacific in the
married name, Aboriginal or skin name, alias, adoptive name, 19th Century.
foster name)?
Are you of Australian South Sea Islander descent?
Other name
No
Yes
12 Do you need a duplicate Medicare card?
Type of name (for example, name before marriage) A duplicate card is a copy of your Medicare card. If you have
more than 1 person on your Medicare card you may find it
useful to have a duplicate card.
5 Your date of birth
No
/ /
Yes
6 Your gender 13 Read this before answering the following question.
Male You only need to complete person 2 to person 4 details if
Female there are more people on your Medicare card who are
7 Your permanent address wanting to copy or transfer with you.
Does a second person need to copy or transfer?
No Go to 40
Yes
Postcode

8 Your postal address (If different to above) Person 2

14 I would like to:
Tick one only
Postcode transfer to a new card
9 Daytime phone number copy to a new card
( ) transfer to an existing card
copy to an existing card
Email
15 Medicare card number person 2
 Ref no.

MS011.2008 2 of 6
 Person 3
16 Mr Mrs Miss Ms Other
23 I would like to:
Family name
Tick one only
transfer to a new card
First given name copy to a new card
transfer to an existing card
Second given name copy to an existing card
24 Medicare card number person 3
Ref no.
17 Your date of birth / /

18 Your gender Male Female

25 Mr Mrs Miss Ms Other
Family name
19 Read this before answering the following question.
This question is voluntary and will not affect your application.
If you do answer, the information will help us to continue to First given name
improve services to Aboriginal and Torres Strait Islander
Australians.
You can have this information removed from Medicare Second given name
records at any time by calling the Aboriginal and Torres Strait
Islander Access Line on 1800 556 955 or by visiting one of
our service centres. 26 Your date of birth / /
Call charges may apply.
27 Your gender Male Female
Are you of Aboriginal or Torres Strait Islander Australian
descent?
28 Read this before answering the following question.
If you are of both Aboriginal and Torres Strait Islander Australian This question is voluntary and will not affect your application.
descent, tick both ‘Yes’ boxes. If you do answer, the information will help us to continue to
No improve services to Aboriginal and Torres Strait Islander
Australians.
Yes – Aboriginal Australian
You can have this information removed from Medicare
Yes – Torres Strait Islander Australian
records at any time by calling the Aboriginal and Torres Strait
20 Read this before answering the following question. Islander Access Line on 1800 556 955 or by visiting one of
This question is voluntary and will not affect your payment. our service centres.
If you do answer, the information will help us to continue to Call charges may apply.
improve services to people of Australian South Sea Islander
Are you of Aboriginal or Torres Strait Islander Australian
descent.
descent?
Australian South Sea Islanders are the descendants of Pacific If you are of both Aboriginal and Torres Strait Islander Australian
Islander labourers brought from the Western Pacific in the descent, tick both ‘Yes’ boxes.
19th Century.
No
Are you of Australian South Sea Islander descent? Yes – Aboriginal Australian
No Yes – Torres Strait Islander Australian
Yes 29 Read this before answering the following question.
21 Signature of person 2 if aged 15 years and over. If you are under This question is voluntary and will not affect your payment.
15 years of age, parent or guardian authorisation is required at If you do answer, the information will help us to continue to
question 51. improve services to people of Australian South Sea Islander
descent.
On completion, print and sign by hand.
- Australian South Sea Islanders are the descendants of Pacific
Islander labourers brought from the Western Pacific in the
22 Does a third person need to copy or transfer? 19th Century.
No Go to 40 Are you of Australian South Sea Islander descent?
Yes No
Yes

MS011.2008 3 of 6
30 Signature of person 3 if aged 15 years and over. If you are under 38 Read this before answering the following question.
15 years of age, parent or guardian authorisation is required at This question is voluntary and will not affect your payment.
question 51. If you do answer, the information will help us to continue to
improve services to people of Australian South Sea Islander
On completion, print and sign by hand.
- descent.
Australian South Sea Islanders are the descendants of Pacific
31 Does a fourth person need to copy or transfer? Islander labourers brought from the Western Pacific in the
No Go to 40 19th Century.
Yes Are you of Australian South Sea Islander descent?
No
Person 4 Yes

32 I would like to: 39 Signature of person 4 if aged 15 years and over. If you are under
15 years of age, parent or guardian authorisation is required at
Tick one only
question 51.
transfer to a new card
copy to a new card On completion, print and sign by hand.
transfer to an existing card -
copy to an existing card If more people need to be added, provide a separate
33 Medicare card number person 4 sheet with their details and signatures.

Ref no.
Existing Medicare card details
34 Mr Mrs Miss Ms Other
40 Are persons 1, 2, 3 or 4 copying or transferring to an existing
Family name Medicare card?
Provide details of the person on the existing Medicare card to
First given name which additional name(s) are to be added. This person must
be aged 15 years and over.
No Go to 51
Second given name
Yes
41 Medicare card number
35 Your date of birth / / Ref no.
36 Your gender Male Female 42 Mr Mrs Miss Ms Other
37 Read this before answering the following question. Family name
This question is voluntary and will not affect your application.
If you do answer, the information will help us to continue to First given name
improve services to Aboriginal and Torres Strait Islander
Australians.
You can have this information removed from Medicare Second given name
records at any time by calling the Aboriginal and Torres Strait
Islander Access Line on 1800 556 955 or by visiting one of
our service centres. / /
43 Your date of birth
Call charges may apply.
44 Your gender Male Female
Are you of Aboriginal or Torres Strait Islander Australian
descent? 45 Permanent address
If you are of both Aboriginal and Torres Strait Islander Australian
descent, tick both ‘Yes’ boxes.
No
Postcode
Yes – Aboriginal Australian
Yes – Torres Strait Islander Australian 46 Postal address (if different to above)

Postcode

MS011.2008 4 of 6
47 Daytime phone number Parent or guardian authorisation
( )
51 Read this before answering the following question.
Email
Only complete this question if you are copying or transferring
a child under 15 years of age.
To copy a child under 15 years of age to a new or existing
48 Read this before answering the following question.
Medicare card, the signature of at least one parent or
This question is voluntary and will not affect your application. guardian is required.
If you do answer, the information will help us to continue to
Where it is not possible for a parent or guardian to authorise
improve services to Aboriginal and Torres Strait Islander
the copy of a child to another card, the primary carer must
Australians.
provide relationship documents or evidence that the child is in
You can have this information removed from Medicare their care.
records at any time by calling the Aboriginal and Torres Strait
To transfer a child under 15 years of age to a new or existing
Islander Access Line on 1800 556 955 or by visiting one of
Medicare card, the signature of both parents or guardians (if
our service centres.
applicable) is required.
Call charges may apply.
Are persons 1, 2, 3 or 4 under 15 years of age?
Are you of Aboriginal or Torres Strait Islander Australian
No
descent?
If you are of both Aboriginal and Torres Strait Islander Australian Yes Your relationship to the child(ren) under 15 years of
descent, tick both ‘Yes’ boxes. age (for example, grandparent)
No
Yes – Aboriginal Australian I declare that:
Yes – Torres Strait Islander Australian • I have read and understood the Privacy notice contained in
49 Read this before answering the following question. this form.
I authorise:
This question is voluntary and will not affect your payment.
If you do answer, the information will help us to continue to • the changes requested for the child(ren) listed on this form.
improve services to people of Australian South Sea Islander Full name of parent or guardian 1
descent.
Australian South Sea Islanders are the descendants of Pacific
Islander labourers brought from the Western Pacific in the Signature of parent or guardian 1
19th Century.
Are you of Australian South Sea Islander descent?
- On completion, print and sign by hand.

No Date
Yes / /
50 I declare that:
Full name of parent or guardian 2
• I have read and understood the Privacy notice contained in
this form.
Signature of person on the existing Medicare card Signature of parent or guardian 2

-
On completion, print and sign by hand. - On completion, print and sign by hand.

Date
Date
/ /
/ /

MS011.2008 5 of 6
Bank account details Privacy notice
All payments are made through Electronic Funds Transfer (EFT). 54 The privacy and security of your personal information is
Payments cannot be made via EFT if the nominated account has important to Services Australia, and is protected by law. We
restrictions on EFT deposits. need to collect this information so we can process and manage
Do not include an account used exclusively for funding from the your applications and payments, and provide services to you.
National Disability Insurance Scheme. We only share your information with other parties where you
have agreed, or where the law allows or requires it. For more
52 Name of bank, building society or credit union information, go to servicesaustralia.gov.au/privacy
www.

Declaration to confirm copy or transfer request

Branch number (BSB)
55 This question is to be completed by person 1. If person 1 is a
child under 15 years of age, a parent or guardian will need
Account number (this may not be the card number)
to sign the declaration on their behalf.

I declare that:
Account held in the name(s) of
• I have read and understood the Privacy notice contained in
this form.
• the information I have provided in this form is complete and
correct.
Consent to nominate bank account I understand that:
• giving false or misleading information is a serious offence.
53 Read this before answering the following question.
Full name of person 1
Only complete this question if other people listed on your
Medicare card (aged 14 years and over) agree to use your
bank account for their Medicare payments, where they are Signature of person 1
the claimant (the person who paid for the service). Date
On completion, print and
Persons 14 years of age and over must sign and give their - sign by hand.  / /
consent for payments to go into the nominated bank account.
I declare that: OR
• I have read and understood the Privacy notice contained in Full name of parent or guardian
this form.
I authorise for: Signature of parent or guardian
• payments to be made into this account. Date
On completion, print and
Full name of person 1 - sign by hand.  / /

Signature of person 1 Reset form Print form

Date
On completion, print and
- sign by hand.  / /

Full name of person 2

Signature of person 2
Date Office use only
On completion, print and
- sign by hand.  / / Type of identification and/or relationship documentation sighted
(for example, driver’s licence).
Full name of person 3
Comments
Signature of person 3
Date
On completion, print and
- sign by hand.
 / / Operator number Date
/ /
Branch

MS011.2008 6 of 6