Application for Medical Entitlement Statement

Use this form if you’re claiming an exemption from the Medicare levy and need a statement showing you’re not eligible for Medicare. After submitting this form you will receive an email with a completed MES form and instructions on what to do next.

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1Applicant Details

2Eligibility for Medicare

3Claiming Period

4Declaration

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Is Tax Agent?

Title*

Name*

First Name Family Name

Gender*

Male

Female

Date of Birth*

Day

Month

Year

Phone*

Email*

Residential Address*

Unit Street Address City Post Code

Is residential and postal address same

My residential address and postal address are same

Postal Address*

Unit Street Address City Post Code

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

Do you have a current or expired Medicare card?*

Yes

Medicare Card Number*

First 4 digits*

Next 5 digits*

Last Digit*

Ref no.*

Your country of residence before coming to Australia*

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

Total Number of Years*

and/or months*

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)?*

Yes

Are you from Finland, Malta or Norway?*

Yes

Did you enter Australia on a student visa?*

Yes

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)?*

Yes

Date of application lodged*

Day

Month

Year

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

Yes

Indicate if the application for Permanent Residency was:*

PR Approval Date*

Day

Month

Year

PR Withdrawn Date*

Day

Month

Year

PR Rejected Date*

Day

Month

Year

Have you lodged an appeal against that decision?*

Yes

Have you lodged more than one Permanent residency application?*

Yes

Date of 2nd application lodged*

Day

Month

Year

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

Yes

Indicate if the 2nd application for Permanent Residency was:*

PR Approval Date*

Day

Month

Year

PR Withdrawn Date*

Day

Month

Year

PR Rejected Date*

Day

Month

Year

Have you lodged an appeal against that decision?*

Yes

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

Yes

In which category did you apply?*

Aged Parent

Contributory Parent

Date of application lodged*

Day

Month

Year

Which financial year are you applying for?

Financial Year From*

Financial Year To*

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

Yes

Expected Departure Date*

Day

Month

Year

Consent*

I agree to the following.

I declare that:
• I have provided all relevant documents.
• for the period(s) specified in question 19, I was a resident
of Australia for taxation purposes, and at the same time I
was not eligible for Medicare benefits, nor Medicare
benefits under a Reciprocal Health Care Agreement.
• the information I have provided in this form is complete and
correct.
I understand that:
• information regarding this application is exchanged
between Medicare and the Australian Taxation Office.
• we may contact the Department of Home Affairs to obtain
information relating to my immigration status (if required).
• giving false or misleading information is a serious offence.

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Date*

Day

Month

Year

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Consent

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A separate application is lodged for each financial year

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All questions in the form have been completed

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The application form has been completed and dated by the applicant

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A certified copy of the photo page of the applicant’s passport

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Visa evidence – endorsed in passport/email or letter from the Department of Home Affairs

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A certified copy of evidence of a current or expired Health Insurance card/medical insurance card or letter showing expiry date (if you answered Yes at question 15)

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A letter or email from the Department of Home Affairs that confirms the date you lodged your application. You can get copies of these letters or emails from your

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

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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

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You provide a signed letter declaring that you have not lodged an appeal

Application for Medicare Entitlement Statement

Use this form if you’re claiming an exemption from the Medicare levy and need a statement showing you’re not eligible for Medicare. After submitting this form you will receive an email with a completed MES form and instructions on what to do next.