Title: Select Title Master Miss Mr Mrs Ms

* Given name(s):

* Family name:

Preferred name (if applicable):

* Date of birth (dd/mm/yyyy):

* Residential Address:

* Suburb / Town:

* Postcode:

Postal Address Details (if different from residential address)

Postal Address:

Suburb / Town:

Postcode:

Mobile or landline number:

Email:

Are you of Aboriginal and / or Torres Strait Islander origin?     

Preferred contact person (if different from patient)

Name:

Relationship:

Mobile or landline number:

Email address:

How would you like us to contact you? (You may select more than one option)     

Medicare Card Number (including person number):

- -

Expiry Date (MM/YYYY):

Please tick if any of the following apply to you:

  

The information provided is true and accurate at the time of application. I give my permission for Hospital and Health Service staff to obtain information about my / my child's / my ward's medical condition for the purpose of administering my application and to disclose relevant information, including a copy of this form, to approved travel / accommodation providers for the purpose of administration of the Patient Travel Subsidy Scheme (PTSS). I understand that I must keep copies of receipts / invoices for accommodation and transport, and may be asked to provide these to Hospital and Health Service staff.

Personal information collected by Queensland Health is handled in accordance with the Information Privacy Act 2009. Your personal information is being collected in order to assess whether you are eligible to receive a subsidy under the Patient Travel Subsidy Scheme. The personal information provided by you will be securely stored and made available to appropriately authorised officers of Queensland Health. Personal information recorded on this form will not be disclosed to other parties without your consent, unless required by law. For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal information, please see our website at www.health.qld.gov.au