Contact Information Telehealth Consult Agreement Under the New Medicare Bulk Billing Scheme, it is a requirement to have your written consent to bulk bill your telehealth consultations. Please fill in the below form: Your name Your email Date of Birth Dr Name Date of consultation Agreement If you agree to the assignment of the Medicare benefit directly to the health professional (bulk bill), submit this form. Details of the TeleHealth consultation to be claimed with Medicare: Usual Item number: 91891 Benefit amount: $41.40 Regards HSM Privacy note: Your personal information is protected by law, including the Privacy Act 1988, and is collected by Services Australia for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the agency, or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations). You can get more information about the way in which the agency will manage your personal information, ‘Yes, I agree to the assignment of the Medicare benefit directly to the health professional. The patient’s name or the name of parent or guardian (where a child is the patient and unable to sign) : Tap to sign here ↓ (required): Clear
