Simplified Billing or ECLIPSE adjustment claim form (HW023)

Use this form to adjust a previously processed claim which needs to be amended with new or altered information.

Download and complete the Simplified Billing or ECLIPSE adjustment claim form.

This form should be used by medical practices, providers, private health insurers and billing agents.

ECLIPSE is the Electronic Claim Lodgement and Information Processing Service Environment.

This PDF is fillable. Download this form and complete it on your device, or print it and complete it by hand.

If you have a disability or impairment and use assistive technology, there are other ways you can do your business with us. You can use self service or request someone to deal with us on your behalf. If you can’t access our forms, please contact us. We can help you access, complete and submit them.

Page last updated: 4 February 2020