BB

Full Name*

Date of Birth*

Medicare Card Number*

I confirm that the details above relating to me (or the patient I am authorised to act for) and the service(s) listed are correct. I agree to assign my right to the Medicare benefit(s) payable for the service(s) described above directly to the practitioner named above, and I accept that the Medicare benefit constitutes full payment for those service(s), meaning I will not be charged any out-of-pocket fee for them. I understand this assignment applies only to the service(s) listed in this agreement, that I am not obliged to assign my benefit and may instead choose to be privately billed, and that a copy of this completed agreement will be provided to me and retained by the practice for a minimum of two years, as required under the Health Insurance Act 1973.*

I have read, understood and agree to the above. (This constitutes my electronic signature)

Date of Service*

Today's Date:*

Bulk Billing - Assignment of Benefit Form

Please submit this form after each bulk billed appointment, as per agreement with your Psychologist.

Information of Service to be Bulk Billed:

Practitioner: Gustavo Gallo Bolzani

Profession: Psychologist (AHPRA PSY0001897406)

Medicare Provider Number: 5166087A

Practice Address: PO Box 159 Broadbeach QLD 4218

MBS Item Number: 91170

Fee: $119.45 - Benefit: $101.55

Group - M18 - Allied Health and other primary health care telehealth services

Subgroup - 2 - Psychologist focussed psychological strategies video services

Address

3b, 91 Upton St. Bundall - QLD 4217

Contacts

E-mail: quironpsychology@gmail.com

Phone: 0420 647 701 (call, text or WhatsApp)

Address:

Po Box 159
Broadbeach QLD 4218

Contact:

quironpsychology@gmail.com

0420 647 701

Gustavo Gallo Bolzani

Other helpful phone numbers:
If you or someone close to you are in immediate danger, please call 000 (triple zero).

Lifeline (Helpline): 13 11 14

Family and Domestic Violence: 1800RESPECT (that's: 1800 737 732)

Men's Helpline: 1300 78 99 78

Kid's Helpline: 1800 55 1800

Beyond Blue: 1300 22 46 36 (Mental Health Support)