Application for Medical Entitlement Statement

Claiming Period*

Do you have a current or expired Medicare card?*
NoYes

Medicare Card number*

-

Ref:

Title*

Family Name*

First Name*

Gender*

Date of Birth*

Contact Number*

Email Address*

Residential Address*

Postal Address*

Is the postal address a tax agent’s address?
NoYes

Your country of residence before coming to Australia

How long did you live in this country before coming to Australia?*

Do you hold current or expired health or medical insurance in Belgium, Italy, the Netherlands, Norway or Slovenia (for example European Health Insurance card, Tessera Sanitaria or AIRE registration)?*
NoYes

Attach certified copies of the medical insurance documentation*

Are you from Finland, Malta or Norway?*
NoYes

Did you enter Australia on a student visa?*
NoYes

Have you lodged an application for permanent residency (other than a parent visa) with the Department of Home Affairs, this includes applications for Spouse Combined visas (subclass 820/801) and (subclass 309/100)?*
NoYes

Date application lodged*
Provide a current letter or email from the Department of Home Affairs that confirms the date you lodged your application.*

Is the application for permanent residency that is being considered by the Department of Home Affairs, still ongoing?*
YesNo

Indicate if the application for Permanent Residency was:*

Approval Date*

Withdrawn Date*

Refused Date*

Provide a current letter or email from the Department of Home Affairs that confirms your application has been approved, withdrawn or refused.*

Have you lodged an appeal against that decision?*
NoYes

Provide a signed letter declaring that you have not lodged an appeal*

Provide evidence that an appeal has been lodged with either the Administration Appeals Tribunal, Federal Court, or High Court, or evidence that you have requested Ministerial Intervention.*

Have you lodged more than one Permanent residency application?*
NoYes

Date application lodged*
Provide a current letter or email from the Department of Home Affairs that confirms the date you lodged your application.*

Is the application for permanent residency that is being considered by the Department of Home Affairs, still ongoing?*
YesNo

Indicate if the application for Permanent Residency was:*

Approval Date*

Withdrawn Date*

Refused Date*

Provide a current letter or email from the Department of Home Affairs that confirms your application has been approved, withdrawn or refused.*

Have you lodged an appeal against that decision?*
NoYes

Provide a signed letter declaring that you have not lodged an appeal*

Provide evidence that an appeal has been lodged with either the Administration Appeals Tribunal, Federal Court, or High Court, or evidence that you have requested Ministerial Intervention.*

Have you lodged an application for permanent residency with the Department of Home Affairs under parent category (Aged parent or Contributory parent)?*
NoYes

Aged parentContributory parent
Date of application*

Are you leaving Australia permanently before end of the current financial year?*
NoYes

Expected departure date*

Date of Submission*

I agree to the Terms and Conditons

Application for Medicare Entitlement Statement