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.