Tax Invoice - Medicare Claim

Thank you for booking with Adelaide Dermatology Associates

Please Print this Receipt as a PDF from your email software, then print to your Printer to attach to your Medicare Claim Form

You can apply for a Medicare rebate by visiting https://www.humanservices.gov.au/individuals/forms...,

Print and complete the Medicare claim form, attach this receipt and send it all to Medicare

Alternatively you can submit your medicare claim through your Medicare Online account through MyGov, or the Express Plus Medicare Mobile App.

PATIENT DETAILS
Name:
Address: , , ,
Medicare Number:
TAX INVOICE / RECEIPT
Adelaide Dermatology Associates
ABN: 45 204 466 593
Invoice No:
Provider
Site: Adelaide Dermatology Associates (Telehealth)
CONSULTATION DETAILS
Date of Video Consultation:
Patient Name:
Appointment Type: . Valid GP referral required.
REFERRAL INFO
Name:
Provider No:
Referred:
Referral Expiry: Valid from 12 months from the date of first video appointment
PAYMENT SUMMARY
GST: $0.00

Total Amount:

Prepayment (deposit):

$

$

Amount Deducted Today

Amount outstanding:

$

$0.00

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