Medicare Claim (MS014) Form

Clinician Specialty: Practice Manager Medicare Claim (MS014) Form **Patient Information** Patient Name: [Sarah Elizabeth Smith] Date of Birth: [05/10/1972] Medicare Number: [5554-321-987-1] Referral Date: [01/10/2024] Referral Expiry Date: [01/04/2025] **Provider Information** Servicing Provider Name: [Dr. Emily White] Servicing Provider Number: [123456DX] Referring Provider Name: [Dr. David Lee] Referring Provider Number: [654321ZY] **Service Details** Date of Service: [01/11/2024] Item Number: [23] Fee Charged: [£75.00] Benefit Paid: [£37.60] Patient Gap: [£37.40] **Claim Notes** [Patient presented for a follow-up consultation regarding ongoing hypertension management. Dr. White provided a script renewal and discussed lifestyle modifications. Claim processed for standard GP consultation item number 23.] **Declaration** I declare that the information provided on this form is true and correct. Signed: [Practice Manager Signature Placeholder] Date: [01/11/2024]