Medicare Two-way claim (MS001)

Purpose of this form Private health insurance member's details

Medicare Two-way is a Services Australia initiative designed to make lodging private health insurer claims
easier for people with private health insurance. Under Medicare Two-way, you can lodge all your in-hospital 1 Name of private health insurer
and ancillary claims either with your participating private health insurer or with Medicare. 2 Private health insurance
There are over 35 private health insurers participating in Medicare Two-way. Contact your private health membership number
insurer to see if they participate in Medicare Two-way or ask at one of our service centres. If you have
questions about private health insurance claims, contact your private health insurer. 3 Family name

Returning this form 4 First given name

• In person at one of our service centres 5 Postal address

Complete this form and a Medicare claim (MS014) form. If you do not have this form, go to Postcode
servicesaustralia.gov.au/forms or visit one of our service centres.
www.

Check that all required questions are answered and that the form is signed and dated. 6 Do you want this recorded as your permanent postal address? No
Provide your original accounts with receipts if the accounts have been paid. Yes
Place in the drop box at one of our service centres.
7 Phone number ( )
We will process your Medicare claim and forward your private health insurance claim to your private
health insurer for processing. Private health insurer payments will be paid by Electronic Funds Transfer
(EFT). To receive payment by EFT, register your bank account details with your private health insurer.
Claiming the private health insurer medical gap benefit
• At a private health insurer
The private health insurer medical gap benefit is the difference between the Medicare benefit and the
Complete your private health insurance claim form as well as a Medicare claim (MS014) form. If you do Medicare schedule fee that your private health insurer will pay for in-hospital services.
not have this form, go to servicesaustralia.gov.au/forms or visit one of our service centres.
www.

Check that all required questions are answered and that the form is signed and dated.
8 Do you want to claim the private health insurer medical gap benefit? No Go to 13
Provide your original accounts with receipts if the accounts have been paid and return your completed forms
and supporting documents to your private health insurer. Your private health insurer will forward your Medicare Yes
claim to Medicare for processing. Your claim will then be processed by us and your private health insurer.
• By post 9 Hospital name
Complete this form and a Medicare claim (MS014) form. If you do not have this form, go to
10 Is this a public hospital? No Go to 12
servicesaustralia.gov.au/forms or visit one of our service centres.
www.

Send your completed form with supporting documents to: Yes

Services Australia
Medicare 11 Did you elect to be treated as a private patient? No
GPO Box 9822 Yes
in your capital city

12 Date of hospitalisation From / / to / /

For more information
Go to servicesaustralia.gov.au/medicare or call 132 011. Call charges may apply.
www.

MS001.2008 1 of 2
 Ancillary claim details Privacy notice
Ancillary services are services such as dental, optical and physiotherapy. Ancillary claims do not attract a 15 The privacy and security of your personal information is important to us, and is protected by law. We need
Medicare benefit. However, as part of the Medicare Two-way service, you are able to complete this form. to collect this information so we can process and manage your applications and payments, and provide
Attach all original accounts with receipts if paid and lodge your ancillary claim at one of our service centres. services to you. We only share your information with other parties where you have agreed, or where the
Your claim will be forwarded to your private health insurer for processing. law allows or requires it. For more information, go to servicesaustralia.gov.au/privacy
www.

13 Are you making a claim for any ancillary services? No  Go to 15

Declaration
Yes
16 I hereby claim benefits for the professional services to which this claim relates and
14 Ancillary claim details
I declare that:
Member's first given name Services provided by Account paid?
• I have paid for, or am liable to pay, the expenses for these services.
No Yes
• there is no entitlement to claim compensation or damages from any other source.
No Yes
• the services were not for the purpose of health screening, superannuation entry or a health
No Yes examination requested by an employer.
No Yes • the information I have provided in this form is complete and correct.

No Yes I understand that:

No Yes • giving false or misleading information is a serious offence.

No Yes I authorise:

No Yes • my private health insurer to contact the provider of any professional service for clarification of any
details in this claim.
• Services Australia to forward my Medicare statement of benefit for in-hospital services associated
with the attached Medicare claim (MS014) form electronically or manually to my private health
insurer.
Date
Private health insurance On completion, print and
member's signature - sign by hand.
 / /

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