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Section A

(patient or guardian / carer to complete)

Date of birth (DD/MM/YY)
(If different from residential address)
(or landline, if mobile not available)
Are you of Aboriginal and / or Torres Strait Islander origin?
(if different form patient)
(or landline, if mobile not available)
How would you like us to contact you? (You may select more than one option)
Section B

(patient or guardian / carer to complete)

A Medicare card number is required to be eligible for PTSS

Expiry date * (MM / YY)
Please tick if an of the following apply to you:
Expiry date * (DD /MM / YY)
(e.g. gold)
Expiry date * (DD / MM / YY)
Expiry date (DD / MM / YY)
Expiry date * (DD / MM / YY)
Section C

(patient or guardian / carer to complete)

The information provided is true and accurate at the time of application. I give my permission for Hospital and Health Service staff to obtain information about my / my child's / my ward's medical condition for the purpose of administering my application and to disclose relevant information, including a copy of this form, to approved travel / accommodation providers for the purpose of administration of the Patient Travel Subsidy Scheme (PTSS). I understand that I must keep copies of receipts / invoices for accommodation and transport, and may be asked to provide these to Hospital and Health Service staff.

(if 18 years or over ) or Guardian / Carer (if under 18 years)
Date * (DD / MM / YY)
(if applicable)
Hospital and Health Service use only
Proof of residency sighted /provided (e.g QLD licence, electricity / gas bill, other acceptable documents)?
Concession card(s) sighted /provided?
Date (DD /MM /YY)