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Application for a Medicare Entitlement Statement form (MS015)

Use this form if you aren't eligible for Medicare and are applying for an exemption from the Medicare levy.

To complete the form electronically, save a copy of the form before you start filling it in.

Print, sign and scan the form and email it to the Medicare Entitlement Statement Unit.

We recommended you email documents in PDF.

This PDF is fillable. Download this form and complete it on your device, or print it and complete it by hand.
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Page last updated: 15 August 2017

This information was printed Tuesday 22 August 2017 from humanservices.gov.au/customer/forms/ms015 It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.