Consumer Registration Form Lodge your completed form: Complete this form if you would like to register for My eHealth Record. You can also register children in your care under the age of 16 years in section 3. For more information free call 1800 619 411 or visit Post: GPO Box 156 Darwin NT 0801 Fax: (08) 8924 7266 Email: Registration Change of details New Registration New Child/ren Registration only Change of Address Change to Adult status Change of Name Other Section 1 Applicant Details Given Name/s: Family Name: Other names you are known by: Including any previous This information is required to assist in identifying you correctly Date of Birth: DD/MM/YYYY / / Gender : Male Female Residential Address: Mailing Address: Contact Numbers: Email: May be used to contact you Nominated Health Centre/s or GP Practice/s: This information is used to send a health profile for you to My eHealth Record Medicare Number: - Each box must contain a number see back page. Section 2 The following questions are optional Medicare - I give permission for a copy of the information on page 1 of this form (& page 2, if you have listed any children in your care) to be provided to Medicare. Next of Kin Details - This information assists with matching you with your healthcare records. It is not used to notify your next of kin in an emergency. Privacy Note Yes No (see back page for more information) Full Name: Relationship to Applicant: Are you of Aboriginal and/or Torres Strait Islander (TSI) origin? Aboriginal TSI Aboriginal/TSI No The information provided in this form will be used to register you and any children listed in Section 3 for My eHealth Record. This information will be entered into your and/or your children’s record/s in My eHealth Record and may be disclosed, together with a copy of this form, to participating healthcare providers. The form signed by you will be held securely by My eHealth Record. If you have agreed to send a copy of pages 1 and 2 of this form to Medicare Australia, they may retain the copy. FOR OFFICE USE ONLY HRN My eHealth Record No
Section 3 - Registration for Children under the age of 16 NOTE: It is optional to supply information in sections of this form marked with asterisks* 1 Child 2 Given Name/s Given Name/s Family Name Family Name Other Name/s Other Name/s Date of Birth / / Date of Birth / / Gender Male Female Gender Male Female *Is the child of Aboriginal or Torres Strait Islander origin? Yes - Aboriginal Yes - TSI Yes - Aboriginal/ TSI No *Is the child of Aboriginal or Torres Strait Islander origin? Yes - Aboriginal Yes - TSI Yes - Aboriginal/ TSI No Medicare Number - Medicare Number - Your relationship to this child I am the child’s: Your relationship to this child I am the child’s: OFFICE USE HRN HC OFFICE USE HRN HC Child 3 Child 4 Given Name/s Name/s Family Name Family Name Other Name/s Other Name/s Date of / / Date of Birth / / Gender Male Female Gender Male Female *Is the child of Aboriginal or Torres Strait Islander origin? Yes - Aboriginal Yes - TSI Yes - Aboriginal/ TSI No *Is the child of Aboriginal or Torres Strait Islander origin? Yes - Aboriginal Yes - TSI Yes - Aboriginal/ TSI No Medicare Number - Medicare Number - Your relationship to this I am the child’s: Your relationship to this child I am the child’s: OFFICE USE HRN HC OFFICE USE HRN HC Child 5 Child 6 Given Name/s Given Name/s Family Name Family Name Other Name/s Other Name/s Date of / / Date of Birth / / Gender Male Female Gender Male Female *Is the child of Aboriginal or Torres Strait Islander origin? Yes - Aboriginal Yes - TSI Yes - Aboriginal/ TSI No *Is the child of Aboriginal or Torres Strait Islander origin? Yes - Aboriginal Yes - TSI Yes - Aboriginal/ TSI No Medicare Number - Medicare Number - Your relationship to this child