Practice Incentives Program Indigenous Health Incentive and
Pharmaceutical Benefits Scheme Co-payment Measure
patient registration and consent
Purpose of this form
Complete this form to register eligible patients with your practice for the Practice Incentives Program (PIP) Indigenous Health Incentive and/or the Pharmaceutical Benefits Scheme (PBS) Co-payment Measure.
Important information
Health Professional Online Services (HPOS) provides secure and convenient online services for health professionals and administrators.
Using your Provider Digital Access (PRODA) account details, you can register patients and update your practice details through HPOS. Changes you make through HPOS are effective immediately.
To register for a PRODA account or to find out more about HPOS, go to humanservices.gov.au/hpos
If you are unable to register using HPOS, you can complete this form and fax it to us for manual processing.
Filling in this form
•	Please use black or blue pen
•	Print in BLOCK LETTERS
•	Mark boxes like this with a ✓ or x
Returning your form
Check that all required questions are answered and the form is signed and dated.
Fax the completed form to 1300 587 696
For more information
Go to humanservices.gov.au/pip
If you need assistance completing this form, email pip@humanservices.gov.au or call 1800 222 032 Monday to Friday, between 8.30 am and 5.00 pm, Australian Central Standard Time.
Note: Call charges may apply.
Practice details
1.	Practice ID

2.	Practice name

3.	Australian Business Number (ABN)

4.	Full practice address – main practice address

The practice address should be the practice location that provides the highest number of services per year.

Building name

Unit	Suite	Shop	Floor number

Street number

Street name

Suburb

State	Postcode

Patient registration requirements
5.	Has the patient been registered for the PIP Indigenous Health Incentive through PIP Online?

If you register the patient through PIP Online, the Patient consent must be completed and retained at the practice.
Practices should only send this form to the Australian Government Department of Human Services if you are not registering the patient through PIP Online.

	No		   All questions in this form must be completed.
	Yes 		  	The Patient consent must be completed and retained at the practice.
6.	Does the patient have a chronic disease?
	No		The patient is at risk of a chronic disease and can only be registered for the PBS Co-payment Measure.
	Yes 		The patients can be registered for the PIP Indigenous Health Incentive and PBS Co-payment Measure.

Annual re-registration for the PBS Co-payment Measure is not required. However, the patient must be re-registered annually for the PIP Indigenous Health Incentive.

7.	Has the patient had, or been offered, the appropriate health assessment for Aboriginal and Torres Strait Islander peoples? 
	No		The patient cannot be registered for the PIP Indigenous Health Incentive but may be eligible for the PBS Co-payment Measure.
	Yes 		The patient can be registered for the PIP Indigenous Health Incentive and the PBS Co-payment Measure.

If the patient is under 15 years of age, they are not eligible to be registered for the PIP Indigenous Health Incentive but may be eligible for the PBS Co-payment Measure. Eligible patients will be registered for the PBS Co-payment Measure.

Patient details
8.	Medicare card number                                                    Ref no.

9.	Patient’s name

Complete the following question using the patient’s details
registered with Medicare.

Dr 	Mr 	Mrs 	Miss 	Ms 	Other 

Family name

First given name

Second given name

10.	Date of birth

     /      /

11.	Gender
	Male 		
	Female		
12.	Is the patient of Aboriginal or Torres Strait Islander Australian descent? 
If the patient is of both Aboriginal and Torres Strait Islander Australian descent, tick both ‘Yes’ boxes. 
	No		The patient cannot be registered for the PIP Indigenous Health Incentive or the PBS Co-payment Measure.
	Yes – Aboriginal Australian	
	Yes – Torres Strait Islander Australian	
Patient consent

The patient must complete the following questions and sign the Patient declaration.

13.	I want the practice written on this form to be my usual care provider and look after my chronic disease and/or chronic disease risk factor.
No 		You cannot be registered for the PIP Indigenous Health Incentive at this practice.
Yes		
14.	I have been told how participation in the PIP Indigenous Health Incentive will help my practice provide better care for my chronic disease. I understand what I have been told and want this practice to register me for this program.
No 		You cannot be registered for the PIP Indigenous Health Incentive at this practice but will be registered for the PBS Co-payment Measure if eligible.
Yes		
15.	I have been told how participation in the PBS Co-payment Measure will make my PBS medicines cheaper. 
I understand what I have been told and I want this practice to register me for this program.
No 		You cannot be registered for the PBS Co-payment Measure at this practice.
Yes		
Privacy notice
16.	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 purposes of the Practice Incentives Program (PIP).
Your personal information will be disclosed to the Australian Government Department of Health to enable that department to administer aspects of PIP, including for program compliance purposes, for statistical and research purposes and to inform policy development.
Your personal information may be used by the Department of Human Services, 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 of Human Services will manage your personal information, including our privacy policy, at humanservices.gov.au/privacy
 Patient declaration
17.	I acknowledge and consent that:
•	my personal details I have provided in this form will be shared between this practice, the Australian Government Department of Human Services and the Australian Government Department of Health for the purposes of the Practice Incentives Program Indigenous Health Incentive and/or the Pharmaceutical Benefits Scheme Co-payment Measure.
I declare that:
•	the information I have provided in this form is complete and correct.
I understand that:
•	general participation information will be used to see how well the program is working and help improve services for Aboriginal and Torres Strait Islander peoples.
•	I can withdraw my consent to participate in the Practice Incentives Program Indigenous Health Incentive and/or the Pharmaceutical Benefits Scheme Co-payment Measure at any time.
•	giving false or misleading information is a serious offence.
Patient or parent/guardian’s full name

Patient or parent/guardian’s signature

 
Date
Date

/      /

	
Practice declaration

This form must be signed by the general practitioner responsible for the care of the patient and the practice’s authorised contact person.
The authorised contact person must be registered on the practice profile in the Practice Incentives Program.

18.	I/We agree to:
•	advise the Australian Government Department of Human Services of any changes to practice arrangements at least 7 days before the relevant point-in-time date.
I/We declare that:
•	the practice will adhere to the eligibility requirements for the Practice Incentives Program Indigenous Health Incentive as set out in the guidelines.
•	the patient has been fully informed of the Practice Incentives Program Indigenous Health Incentive and/or the Pharmaceutical Benefits Scheme Co-payment Measure.
•	the information I/we have provided in this form is complete and correct.
I/We understand that:
•	if the Australian Government Department of Human Services is not informed of any changes to practice arrangements, incentive payments may be reduced or recovered and the practice’s eligibility for the Practice Incentives Program may be affected.
•	the Australian Government Department of Health may conduct program audits of a practice’s compliance with the Practice Incentives Program eligibility requirements.
•	the practice is required to retain practice documentation for a period of 6 years.
•	I/we may be required to provide information to the Australian Government Department of Health as evidence of the practice’s compliance with the Practice Incentives Program Indigenous Health Incentive payments.
•	if I/we cannot provide information, as requested by the Australian Government Department of Health, to enable the Australian Government Department of Health to establish the practice’s compliance with the Practice Incentives Program Indigenous Health Incentive, I/we acknowledge that past Practice Incentives Program payments may be recovered and that future payments may be suspended or ceased.
•	giving false or misleading information is a serious offence.
General practitioner’s full name

General practitioner’s signature

 
Date
Date

/      /

	
Authorised contact person’s full name

Authorised contact person’s signature

 
Date
Date

/      /

IP017.1707