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.
If you use assistive technology because of a disability or impairment we provide help for assistive technology users of forms.

Page last updated: 2 December 2016

This information was printed Thursday 8 December 2016 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.