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Two Kidneys

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  • Phone : 02 4321 0555
  • Fax : 02 4321 0125
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Assignment of Benefit
DB4 – Pre-assignment

Medicare – Online Claiming

Bulk Bill Assignment of Benefit Agreement

Bulk Bill Claim for assessment by Services Australia

(This data set is an approved data set as prescribed in the Health Insurance Regulations 2018)

Required fields

Patient Details

Please enter your details exactly as they appear on your Medicare card.

The 10-digit number on your Medicare card.

The number beside your name on the card.

Referral & Provider Details

Choose your practitioner and the period of your referral.

Service Details

Your appointment date.

Assignment of Benefit

Please read the privacy notice, tick the assignment box and sign below.

Agreement Type
Pre-assignment

Privacy Notice: Services Australia collects and handles your personal information in accordance with the Privacy Act 1988, for the purpose of assessing entitlement to, and administration of, payments and services.

This information has been collected to enable Services Australia to process your digital claim. Failure to provide this information to Services Australia may prevent you from accessing bulk billing.

Your personal information may be used by the agency or disclosed to other parties for the purposes of research, investigation or where you have agreed, or if required or authorised by law.

You can read Services Australia's Privacy Policy by visiting servicesaustralia.gov.au/privacy, which includes information about:

  • how Services Australia handles your personal information,
  • accessing or requesting a change to your personal information,
  • how you can make a complaint if you think your privacy has been breached.

To be completed by the person assigning benefits for the services stated on this form.

Patient or Assignor Signature

Agreement Date
28/10/2026
Is the assignor the patient?

Your details are sent securely and kept confidential.