Medicare Form

Title *

First Name *

Last Name *

Date of Birth *

Gender *

Email Address

Phone number *

Street Address *

Suburb *

State *

Post Code *

Parent / Gradian Information

First Name

Surname

Phone number

Location of services

Medicare Details

Medicare Number *

Medicare Expiry Date

Medicare IRN *

Doctors Name *

Doctors Phone Number

Doctors Address

Doctors Provider No *

Please note if you require an OT Assessment or Speech Assessment you will have to select your payer as a Private client. This will incur an out of pocket expense.

Medicare Disiplines *

Occupational Therapy - Please note Medicare does not cover AssessmentsSpeech Therapy - Please note Medicare does not cover AssessmentsPhysiotherapyExercise PhysiologyDieteticsPodiatry

Medicare Dicipline *

PhysiotherapyExercise PhysiologyDietetics

How many sessions have you been given. *

Please note there is an out of pocket expense as Medicare does not cover the entire cost of your appointment.

Are you under the age of 16? *

YesNo

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Date of Birth *

Parent/Guardian Contact Number *

Please upload a copy of your EPC

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Comments

I have read and consent to the Pre-Paid Policy *

I consent for Optimum Health Solutions to obtain, release and discuss information that is relevant to the services being provided. This may include verbal and written communication regarding past and present treatment & services.

Key Parties may include, but are not limited to, some or all of the following:

• LAC/ NDIS Plan Coordinator
• Treating Medical Practitioner (GP) / Medical Specialists
• Other Allied Health Professionals
• Support Coordinators/Case Coordinators
• Relevant Support Workers/ Key Support Workers
• Service Providers/Suppliers
• Immediate Family Member
• Guardians/Power of Attorney/Participant Nominated Representative

*

Name of person signing *

Signiture *

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Date *

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Clinic Contact Information

Batemans Bay - 02 8064 9105

batemansbayclinic@opt.net.au

3/34 Orient Street

Batemans Bay

NSW 2536

Liverpool - 02 8599 6281

liverpoolclinic@opt.net.au

5/33 Heathcoate Road

Moorebank
NSW 2170

Blacktown - 02 8599 6275

blacktownclinic@opt.net.au

2/114 Main Street

Blacktown

NSW 2148

Campbelltown - 02 8599 6275

campbelltownclinic@opt.net.au

Inside Aquafit (Rehab)

Old Menangle Rd,

Campbelltown

NSW 2560

Speech Therapy & Occupational Therapy

25 Iolanthe Street

Campbelltown

NSW 2560

Cessnock - 02 4990 1046

cessnockclinic@opt.net.au

Unit 1, 384 Wollombi Road

Bellbird

NSW 2325

Croydon Park - 02 8599 6280

croydonclinic@opt.net.au

227 Georges River Road

Croydon Park

NSW 2133

Goulburn - 02 4810 0700

goulburnclinic@opt.net.au

37 Ross Street

Goulburn

NSW 2580

Hornsby - 02 4810 0700

hornsbyclinic@opt.net.au

Unit 6/30 Leighton Place

Hornsby

NSW, 2077

North Rocks - 02 9053 2997

northrocksclinic@opt.net.au

22 Loyalty Rd

North Rocks

NSW 2151

Nowra - 02 4445 3700

nowraclinic@opt.net.au

8/38-44 Berry Street

Nowra

NSW 2541

Sylvania - 02 8064 9105

sylvaniaclinic@opt.net.au

1/266 Princes Highway

Sylvania

NSW 2224

TAS - 03 6245 0799

tasmaniaclinic@opt.net.au

Mornington

49 Electra Place
Mornington
TAS 7018

Moonah

71 Main Road
Moonah
TAS 7009

Dodges Ferry

517 Old Forcett Road
Dodges Ferry
TAS 7173