Reporting suspected fraud
Purpose of this form
3 Your postal address
Complete this form to report suspected fraud against Medicare
programs.
You are under no obligation to provide personal details when providing
Postcode
information. However, if you provide your name and contact number, it
will allow us to contact you for more information if required.
4 Daytime phone number
If you choose to remain anonymous we would appreciate you
( )
providing as much information as you can, as we will not be able to
Mobile phone number
contact you if we require more information.
For more information
Email
For more information, go to our website
humanservices.gov.au/fraud or call
131 524 Monday to Friday,
@
www.
between 9.00 am and 5.00 pm, Australian Eastern Standard Time.
Note: Call charges apply – calls from mobile phones may be charged
Suspected fraud details
at a higher rate.
5 Who is this report about?
Filling in this form
Tick ONE only
•
Please use black or blue pen
Individual
Go to next question
• Print in BLOCK LETTERS
Business/practice
Go to 9
• Mark boxes like this
with a ✓ or 7
Both
Go to next question
• Where you see a box like this
Go to 5 skip to the question
6 Dr Mr Mrs Miss Ms Other
number shown. You do not need to answer the questions in
Family name
between
.
Returning your form
First given name
Check that you have answered all the questions you need to answer
and that you have signed and dated this form.
Second given name
Send the completed form to:
Department of Human Services
Fraud hotline
7 Date of birth
GPO Box 9822
/ /
SYDNEY NSW 2001
8 Occupation
or
Fax:
1300 657 239
9 Name of organisation
Applicant’s details
1
10
Dr
Mr Mrs Miss Ms Other
Reference number (e.g. Medicare provider number, approval
number, Medicare card number or Australian Business Number
Family name
(ABN)) (if known)
Medicare provider number
First given name
Approval number
Second given name
Medicare card number
2
Ref no.
Date of birth
ABN
/ /
MO029.1504 (formerly 1980)
1 of 2
11 Address
Acknowledgement
15 Would you like an acknowledgement to confirm this form has
been received by the Australian Government Department of
Human Services?
Postcode
No
Go to 17
12 Daytime phone number
Yes
( )
16 I would like an acknowledgement of confirmation sent to my:
Mobile phone number
Postal address
Email
Fax number
Privacy notice
( )
17 Your personal information is protected by law, including the
Email
Privacy Act 1988, and is collected by the Australian Government
Department of Human Services for the assessment and
@
administration of payments and services. This information is
required to process your application or claim.
13 Provide details of the suspected fraud or suspicious activity
Your information may be used by the department or given to
Please include dates, names and locations relevant to your report.
other parties for the purposes of research, investigation or
where you have agreed or it is required or authorised by law.
You can get more information about the way in which the
Department of Human Services wil manage your personal
information, including our privacy policy at
humanservices.gov.au/privacy or by requesting a copy from
www.
the department.
Declaration
18 I declare that:
• the information I have provided in this form is complete and
correct.
I understand that:
• giving false or misleading information is a serious offence.
• personal information may be disclosed under the
Freedom of Information Act 1982
If you require more space, attach a separate sheet
• a person is not required to provide the Australian
with details.
Government Department of Human Services with their
name and/or contact details in reporting suspected fraud.
14 How did you become aware of this matter?
Applicant’s full name
Please include dates, names and locations relevant to your report.
Applicant’s signature
-
Date
/ /
Reset form
Print form
If you require more space, attach a separate sheet
with details.
MO029.1504 (formerly 1980)
2 of 2
