Healthcare Identifiers Service Application to request a pseudonym Individual Healthcare Identifier record form (MS005)

Use this form if you want to create a pseudonym Individual Healthcare Identifier (IHI) if you consider yourself vulnerable or at risk.

You must already have a verified Individual Healthcare Identifier (IHI) record to be eligible for a pseudonym IHI.

You cannot claim Medicare or pharmaceutical benefits using a pseudonym IHI.

 
This PDF is fillable. Download this form and complete it on your device, or print it and complete it by hand.

If you have a disability or impairment and use assistive technology, there are other ways you can do your business with us. You can use self service or request someone to deal with us on your behalf. If you can’t access our forms, please contact us. We can help you access, complete and submit them.

Page last updated: 3 September 2018