Application for late lodgement of a Simplified Billing claim for assigned Medicare benefits form (HW026)

Use this form to apply for late lodgement of a Simplified Billing claim for assigned Medicare benefits if you are a health professional, billing agent or private health insurer.

Download and complete the Application for late lodgement of a Simplified Billing claim for assigned Medicare benefits form.

To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please contact us. We can help you access, complete and submit them.

Page last updated: 8 June 2022