Medicare BulkBilling Session Consent Form

In order for us to claim a bulk bill for our Telehealth session, we must get your written consent.

If you agree to the assignment of the Medicare benefit directly to your psychologist (i.e., you agree to be BulkBilled) please complete, sign, and send this form on this page.


First Name Last Name


Medicare Number (10 digits)
IRN (Number next to your name)
IRN (if a family member)

If you don't have one, you can use a trusted person's email


SelfParent / GuardianPartnerFamilyFriend



First Name Last Name


Eryn BroughtonCandice BowersJeff Broughton

(in YYYY-MM-DD format (e.g. 2013-04-08))
Date: Time: Hour Minute


91168 Video-Conference (Attendance lasting more than 20 minutes but less than 50 minutes) with a benefit of $61.0591183 Telephone-Conference (Attendance lasting more than 20 minutes but less than 50 minutes) with a benefit of $61.0591170 Video-Conference (Attendance lasting at least 50 minutes) with a benefit of $86.1591184 Telephone-Conference (Attendance lasting at least 50 minutes) with a benefit of $86.15My psychologist is not Eryn Broughton

91166 Video-Conference (Attendance lasting more than 20 minutes but less than 50 minutes) with a benefit of $86.1591181 Telephone-Conference (Attendance lasting more than 20 minutes but less than 50 minutes) with a benefit of $86.1591167 Video-Conference (Attendance lasting at least 50 minutes) with a benefit of $126.5091182 Telephone-Conference (Attendance lasting at least 50 minutes) with a benefit of $126.50My psychologist is not Candice Bowers or Jeff Broughton


Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the department, or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations). You can get more information about the way in which the department will manage your personal information at https://www.servicesaustralia.gov.au/organisations/about-us/publications-and-resources/privacy-policy