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Claim Form for reimbursement to Service Provider

: Guidelines
: This form may be completed by member or their registered Service Provider. Submit one form per Service Provider, however, multiple invoices can be included. If member account does not have sufficient funds, invoices will sent to member for direct payment.
Beneficiary (Patient/Client):
Name of Member (Carer):
: Details of Claims being paid directly to Service Provider
Name of Service Provider:
No. of Invoices:
Total $ amount to be deposited into Provider Bank Account:: AUD
Service Providers Banking Details
: Service Provider Banking Details
: If unable to upload invoices, please fax to 07 3870 1123 or post to 14 Munro Street, Auchenflower 4066. Payments will be processed once supporting invoices are received. Hint: Take a picture of invoices on your mobile phone and upload. Please check that the details are able to be read.
BSB Number:
Account No.:
Please upload invoices here: If you cannot upload, fax to 07 3870 1123 or send to 14 Munro Street, Auchenflower

Guidelines