Medicare Pre-assignment Bulk Billing Agreement

Patient Details

Fill in name and relationship below only if you are completing on behalf of the patient

Pre-assignment of your Medicare benefit

This is a pre-assignment agreement. Before your ECG is performed, you are agreeing to assign your Medicare benefit for this service directly to the reporting specialist, who will bulk bill the service. This means Medicare pays the specialist directly and you are not charged for it.

The report may be completed by any of the following specialists at Perth Cardiovascular Institute:

  • Dr Jay Baumwol
  • Dr Matthew Best
  • Dr Andrew Epstein
  • Dr Balvinder Handa
  • Dr Athula Karu
  • Dr Susan Kuruvilla
  • Dr Jonathan Lipton
  • Dr Michael Muhlmann
  • Dr Mary Nangrahary
  • Dr Anne Powell
  • Dr Jamie Rankin
  • Dr Sharad Shetty
  • Dr Nik Stoyanov

    • Place of practice: Suite 12, 1st Floor, 146 Mounts Bay Road, Perth WA 6000

    Service: MBS item 11705, twelve-lead electrocardiography, formal report only, by a specialist or consultant physician.

    Date of this agreement: The date you submit this form

    Date the service will be performed: The day of your appointment

    On pressing the I Agree button a QR code will be generated that needs to be scanned into the ECG machine. Please keep this screen active until it has been scanned.

    Medicare Australia Privacy Note:
    Your personal information is protected by law, including the Privacy Act 1988, and is collected by Services Australia for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the agency, or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations).

    You can get more information about the way in which the agency will manage your personal information, including our privacy policy.