D1221 Health Practitioner Service Voucher

1 Health Practitioner Service Voucher Each Service Voucher must be 1 Complete the Patient Details section by entering the patient's file number, used only for services rendered first name, initial and surname. If the file number is not known, include date of birth and address. by one Practitioner to one patient 2 Complete all relevant sections. 3 The Condition Treated' section must be completed if the veteran holds a Repatriation Health Card for Specific Conditions (WHITE CARD). 4 Please ensure the patient signs the form against each Service . 5 Please submit the Departmental copy with your claim and ensure that any relevant documents are attached.

2 6 Please ensure that the patient receives the Patient copy. 7 The Claimant copy may be retained as your record. 8 The information sought on this form is to enable Service verification and claim processing. This information will be disclosed to the department of Human Services to process the payment. Manual Claiming Mail your treatment vouchers to the appropriate address for processing: Veterans' affairs Processing department of Human Services Providers in VIC, QLD, TAS: GPO Box 9869, Melbourne VIC 3001. Providers in WA, ACT, NSW, NT, SA: GPO Box 9869, Perth WA 6848. Continued on next page D1221 (08/17).

3 australian government P department of Veterans' affairs A PLEASE COMPLETE THIS FORM ONLINE AND THEN PRINT TO SIGN. T Health Practitioner Service Voucher I. E FULL Condition treated NAME (as per LMO's Referral). N. T DATE OF BIRTH Name of Provider who actually ADDRESS. rendered the Service D. E Referring Practitioner 's Name T. A Referring Practitioner 's I Referral Date Provider No. L File number S Doctor's referral form (D904): Retained S Date of Item number Amount claimed Kilometres Patient's signature for services received E Service travelled Patient declaration: R. V / / I am not entitled to claim third I party or Worker's Compensation for C / /.

4 E the services listed. / /. I have received the services listed, D / /. E and my signature appears against T / / each Service . A. I / /. L If treated in a hospital Name of S D1221 (08/17) Original department copy Hospital or Nursing Home Save Print Clear cut on this line australian government P department of Veterans' affairs A PLEASE COMPLETE THIS FORM ONLINE AND THEN PRINT TO SIGN. T Health Practitioner Service Voucher I. E FULL Condition treated NAME (as per LMO's Referral). N. T DATE OF BIRTH Name of Provider who actually ADDRESS. rendered the Service D. E Referring Practitioner 's Name T.

5 A Referring Practitioner 's I Referral Date Provider No. L File number S Doctor's referral form (D904): Retained S Date of Item number Amount claimed Kilometres Patient's signature for services received E Service travelled Patient declaration: R. V / / I am not entitled to claim third I party or Worker's Compensation for C / /. E the services listed. / /. I have received the services listed, D / /. E and my signature appears against T / / each Service . A. I / /. L If treated in a hospital Name of S D1221 (08/17) Duplicate Patient copy Hospital or Nursing Home cut on this line australian government P department of Veterans' affairs A PLEASE COMPLETE THIS FORM ONLINE AND THEN PRINT TO SIGN.

6 T Health Practitioner Service Voucher I. E FULL Condition treated NAME (as per LMO's Referral). N. T DATE OF BIRTH Name of Provider who actually ADDRESS. rendered the Service D. E Referring Practitioner 's Name T. A Referring Practitioner 's I Provider No. Referral Date L File number S Doctor's referral form (D904): Retained S Date of Kilometres Service Item number Amount claimed travelled Patient's signature for services received Patient declaration: E. R. V / / I am not entitled to claim third I party or Worker's Compensation for C / /. E the services listed. / /. I have received the services listed, D / /.

7 E and my signature appears against T / / each Service . A. I / /. L If treated in a hospital Name of S D1221 (08/17) Triplicate Claimant copy Hospital or Nursing Hom