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. 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 contact us. We can help you access, complete and submit them.

Page last updated: 10 February 2021