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.

Print, sign and scan the form and email it to the Medicare Entitlement Statement Unit.

We recommended you email documents in PDF.

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 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: 30 June 2022