Application for a Medicare Entitlement Statement form (MS015)
Use this form if you're not eligible for Medicare and are applying for an exemption from the Medicare levy.
Download and complete the Application for a Medicare Entitlement Statement form.
To complete the form electronically, save a copy of the form before you start filling it in.
Print, sign and scan the form and email it to the Medicare Entitlement Statement Unit.
We recommended you email documents in PDF.
This PDF is fillable. You can fill it out on your device, or print it and complete it by hand.
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 use self service, request someone to deal with us on your behalf, or contact us. We can help you access, complete and submit them.
Page last updated: 10 August 2020
This information was printed 10 September 2021 from https://www.servicesaustralia.gov.au/individuals/forms/ms015. It may not include all of the relevant information on this topic. Please consider any relevant site notices at https://www.servicesaustralia.gov.au/individuals/site-notices when using this material.