Medicare Assignment of Benefit

About This Agreement Medicare requires a signed Assignment of Benefit agreement for every appointment. Completing this digital form prior to arrival—whether for yourself or as a parent, guardian, or carer—helps conserve paper resources and avoids generating physical paperwork at billing, making your check-out much faster.

Medical Service Location *

Chatswood ENT Level 1, Suite 13, 445 Victoria Avenue, Chatswood NSW 2067
Mid North Coast ENT at Kempsey Suite 200, 35 Belgrave Street, Kempsey NSW 2440

Nominated Medical Provider *

Dr Bill Johnston
A/Prof Raewyn Campbell

Medical Date Digital

Patient Name *

First

Last

Patient Date of Birth

Who is completing this agreement? *

Myself (the patient)
Parent / Legal Guardian
Carer / Representative

Patient Medicare Card Details *

Patient Medicare card details are currently on file and unchanged
Patient Medicare card details have changed since initial registration

Medicare Details On File Medicare card details provided during patient registration are automatically applied to this agreement. Please complete the fields below only if card details have changed, expired, or been reissued. If you are unsure, or if our system flags a detail mismatch, our friendly team will assist in updating the information prior to billing.

Medicare Card Number

Ref Number on Card (IRN) *

Signing on Behalf of a Patient Because you are completing this agreement as a parent, legal guardian, or carer, you will be designated as the Assignor for Medicare reporting purposes. Please provide your details below.

Benefits Assignor Name

First

Last

Relationship to Patient *

Outpatient ENT Clinic Item Numbers (Pre-Service Dataset)

The table below outlines potential Medicare Benefits Schedule (MBS) item numbers that may apply to specific clinical procedures or services:

Item	Description of Service	Schedule Fee	Benefit ($)
41764	Nasendoscopy, sinoscopy or fibreoptic examination of nasopharynx or larynx	$147.00	$124.95
41647	Removal of foreign body or wax (cerumen) from external auditory canal via micro-suction	$131.60	$111.85
41677	Removal of foreign body from nasal cavity / arrest of epistaxis	$107.75	$91.60
41632	Aural toilet or microscopic examination/procedure of ear canal	$285.90	$243.00
30071	Diagnostic biopsy of skin, mucous membrane, or soft tissue lesion	$62.60	$53.20
91823	Telehealth specialist attendance (video), subsequent consultation	$52.30	$44.45
91833	Telehealth specialist attendance (phone), subsequent consultation	$52.30	$44.45
104	Specialist attendance, initial consultation	$104.00	$88.40
105	Specialist attendance, subsequent consultation	$52.30	$44.45

Important Note Regarding Specialist Consultations Specialist consultations (MBS items 104 and 105) are privately billed and attract an out-of-pocket fee. Bulk billing for consultation items is exceptional and is not standard practice. This agreement is primarily utilised for specific eligible procedural services or pre-arranged bulk-billed items.

Assignment of Benefit Agreement As the patient, or as the parent, legal guardian, or carer authorised to sign on behalf of the patient, I assign my right to benefits to the health professional who rendered the service(s).

Services Australia Privacy Note: Personal information is handled in accordance with the Privacy Act 1988 to assess entitlement to, and administration of, Medicare payments and services. servicesaustralia.gov.au/privacy

Assignor Digital Signature *

Clear Signature

Date