Claim Cover Sheet MedsCheck Program When to use this form Service Provider details

MedsCheck Program
Claim Cover Sheet
When to use this form
Service Provider details
An approved MedsCheck service provider must submit this claim
cover sheet and the attached MedsCheck program payment
application form in order to receive payment for MedsCheck and/or
Diabetes MedsCheck services conducted. The MedsCheck program
claim cover sheet must be signed by an owner of the Section 90
Pharmacy or person authorised to sign on behalf of the owner.
1 Pharmacy approval number
2 Pharmacy name
3 Address
The information provided by you on this form will be used to
determine your claim for benefits under the MedsCheck program.
Assistance
Postcode
For more information about the MedsCheck program go to
humanservices.gov.au/5cpa >MedsCheck or if you need assistance
completing this form email
sa.guild.govt.prog@medicareaustralia.gov.au or call 08 8274 9641
between 8.30 am and 5.00 pm, Monday to Friday, Australian Central
Standard Time. Note: Call charges apply – calls from mobile phones
may be charged at a higher rate.
4 Postal address (if different to above)
Postcode
5 Daytime phone number
Lodgement
Mobile phone number
Send the completed and signed MedsCheck program claim cover
sheet with one or more MedsCheck program payment application
forms to:
Fax number
(
)
Community Pharmacy Agreement Officer
Pharmaceutical Benefits Section
Department of Human Services
GPO Box 9826
ADELAIDE SA 5001
or
Fax: 08 8274 9373
Business email
@
6 Claim Reference number
7 Number of claims submitted with this cover sheet
Print in BLOCK LETTERS
Tick where applicable ✓
8937.1205
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Declaration
8 I declare that:
• I agree to have any information pertaining to MedsCheck
services forwarded to the Department of Health and Ageing
• the MedsCheck service was conducted in accordance with
the Medication Management Review (MMR) terms and
conditions
• MedsCheck services were provided to an eligible patient
for whom a payment application is submitted for the date
indicated
• documentation in support of the payment application(s) is
available for audit of MedsCheck service payments
• I have permission to pass on the details of the pharmacist(s)
included in the attached form(s) to the Department of Human
Services and/or any other relevant authority
• the information provided by me in the payment application(s)
is true and correct.
Authorised person’s full name
Owner/authorised person’s signature -
Date
/
/
Privacy notice
Centrelink, Medicare Australia, Child Support and CRS Australia are
services within the Australian Government Department of Human
Services (Human Services).
Your personal information is protected by law, including the
Privacy Act 1988. Your information is collected for Social Security,
Family Assistance, Medicare, Child Support and CRS purposes. This
information may be required by the powers provided within each
services’ legislation or voluntarily given by you when you apply for
services or payments.
Your information will be used for the assessment and administration
of payments and services. Your information may also be used within
Human Services, where you have provided consent or it is required or
authorised by law. Human Services may disclose your information to
Commonwealth departments, other persons, bodies or agencies ONLY
where you have provided consent or it is required or authorised by law.
You can get more information about privacy by going to our website
humanservices.gov.au/privacy or requesting a copy of the full
privacy policy at one of our Service Centres.
8937.1205
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