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 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: 1 July 2018