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