ASSISTED REGISTRATION Application to Register for a Personally Controlled Electronic Health Record	

Purpose of this form
This is an application for registration as a consumer under the Personally Controlled Electronic Health Records Act 2012 (PCEHR Act). Registration for an eHealth record is voluntary.
If you would prefer, you can register free of charge online at www.ehealth.gov.au, by phoning 1800 723 471, by mail using a different form, or in a Medicare shopfront.
Important: You need to read the essential information before you sign this application.

Application for yourself
Please provide the following information about yourself
1	Family name
<PtSurname>	

First given name
<PtFirstName>	

2	
	Date of birth	
<PtDoB>	

	

3	
 Sex	
<PtSex>	

4	Provide ONE of the following:
		 Your Medicare card number 
<PtMCNo>	

  OR Your DVA file number
<PtDVANo>	

Please read this before answering question 5

Question 5 is optional. This information will assist in the planning and provision of appropriate and improved healthcare and services. If you do not answer your eHealth record will show ‘not stated’.	

5	Are you of Aboriginal or Torres Strait Islander origin?
q  	No
q	Yes, Aboriginal
q	Yes, Torres Strait
q	Yes, both Aboriginal and Torres Strait Islander

Please read this before answering question 6

Upon the success of your application, we will provide you with an
Identity Verification Code (IVC) to access your eHealth record online.	

6	How do you wish to receive your Identity Verification Code?
q	By email to:
	<PtEmail>	

	q  By SMS to:  <PtPhoneMob>
q  Through the healthcare provider organisation

Authorised staff member notes:

	

	7  Please indicate which Medicare information, if any, you consent to being included in your eHealth record:
q  details of all future claims made for Medicare benefits when you receive a healthcare service that is covered under the Medicare Benefits Schedule*
q  AND details of any past claims for Medicare benefits, if available* (This option is only available if you have selected ‘all future claims’ above.)
q  details of all future claims made for Pharmaceutical benefits when you receive medication that is covered under the Pharmaceutical Benefits Scheme**
q  AND details of any past claims for Pharmaceutical benefits, if available** (This option is only available if you have selected ‘all future claims’ above.)
q  your organ and/or tissue donation decision(s), which are sourced from the Australian Organ Donor Register
q  details of immunisations up until the age of 7, sourced from the Australian Childhood Immunisation Register
Note:
*	includes claims successfully processed on behalf of the Department of Veterans’ Affairs (DVA), in accordance with eligibility entitlements provided by DVA.
**	includes claims successfully processed on behalf of DVA under the
Repatriation Pharmaceutical Benefits Scheme.
8	Application to register and consent to include information
I apply for registration and:
•	declare that the information in this application is correct and any supporting evidence submitted by me is correct
•	consent to records containing my health
information being uploaded to the eHealth record system by registered healthcare provider organisations involved in my care, subject to any express advice I give to my healthcare providers not to upload a particular record, a specified class of records, or any records
•	declare that I have received and read the ‘Essential Information about assisted Personally Controlled Electronic Health Record (eHealth record) registration’ document provided by the assisting healthcare provider organisation

Applicant’s signature

	

Date
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Note: Giving false or misleading information is a serious offence.