Banksia Medical Centre
Bulk billing consent portal
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Patient name *
Provider *
Location
Time
Please enter patient name and provider.
Staff: tap here after patient signs
How would this patient like to consent?
Please read and sign below
Post-service episodic assignment — s.65C(4) Health Insurance Amendment Regulations 2025
Provider
Service date
MBS item * staff
Required
Date of assignment
Medicare Provider No. staff
Required
Schedule fee (benefit amount) staff
Required
Medicare card ref. (last 4 digits — audit only)
Not shown to patient. Stored as masked identifier per s.65C(4).
Patient contact (for digital record)
Captured as part of the digital notification audit trail.
Assignor declaration * — select one
Please select your role before signing.
Medicare bulk billing — assignment of benefit
"Yes, I agree to the assignment of the Medicare benefit directly to the health professional."
By signing below, I authorise the above-named provider to receive my Medicare benefit as full payment for the service rendered. I understand no out-of-pocket fee is payable by me. I have been informed of the MBS item number(s) and the corresponding schedule fee (benefit amount) for this service.
Privacy notice — Services Australia
Your personal information is collected under the Health Insurance Act 1973 to process Medicare bulk billing claims. It may be disclosed to Services Australia and used for compliance and audit purposes. For details visit servicesaustralia.gov.au/privacy.
Signature *
Sign here with your finger
Use your finger or stylus to sign
Alternative consent
Thank you — consent recorded
Saved securely to Banksia Medical Centre records.
Retain 2 years · Provide copy to patient on request (DOH requirement)
Patient
Provider
Item
Benefit
Date
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