HECS Reimbursement Scheme Bank account details form

Higher Education Contribution Scheme
Reimbursement Scheme
Bank account details
When to use this form
Complete this form to update your bank account details under the
Higher Education Contribution Scheme (HECS) Reimbursement
Scheme. The HECS Reimbursement Scheme is a Department of Health
and Ageing initiative administered by the Australian Government
Department of Human Services (Human Services).
For more information
For more information about the HECS Reimbursement Scheme or for
assistance completing this form go to our website
humanservices.gov.au/healthprofessionals > Other programs -
Information for health professionals > Rural programs > HECS
> Reimbursement Scheme or call 1800 010 550 Monday to Friday,
between 9.00 am and 5.00 pm, Australian Central Standard Time.
Note: Call charges apply from mobile phones.
Filling in this form
• Please use black or blue pen
• Print in BLOCK LETTERS
• Mark boxes like this with a ✓ or 7
Returning your form
Check that you have answered all the questions you need to answer
and that you have signed and dated this form.
HECS Reimbursement Scheme
Department of Human Services
GPO Box 2844
ADELAIDE SA 5001
or
Fax to: 1300 588 673
If you fax this form to Human Services you must retain the original
for auditing purposes. If the original document cannot be located, the
faxed copy held by Human Services will be recognised as the original
document.
Applicant’s details
1 Medicare provider number (if applicable)
2 HECS ID (if known)
3 Tax file number
4 Dr Mr Mrs Miss Ms Other
Family name
First given name
5 Daytime phone number
( )
Bank account details
6 Payments will be paid by Electronic Funds Transfer (EFT) into
your nominated bank account.
Note: Medicare benefits cannot be paid via EFT if the
nominated account has restrictions on EFT deposits, is a credit
card, or an overseas account.
We cannot record bank account details for children under
14 years of age.
Name of bank, building society or credit union
Branch where your account is held
Branch number (BSB)
Account number (this may not be your card number)
Account held in the name(s) of
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Declaration
7 I agree to:
• authorise the Department of Human Services to direct all
payments relating to the Higher Education Contribution
Scheme Reimbursement Scheme and the provider number
identified on this form into the nominated bank account.
I declare that:
• the information provided in this form is complete and correct.
I understand that:
• giving false or misleading information is a serious offence.
Applicant’s signature
Date
- / /
Privacy notice
Centrelink, Medicare, Child Support and CRS Australia are services
within the Australian Government Department of Human Services
(Human Services).
Your personal information is protected by law, including the
Privacy Act 1988. Your information is collected for Social Security,
Family Assistance, Medicare, Child Support and CRS purposes. This
information may be required by the powers provided within each
services’ legislation or voluntarily given by you when you apply for
services or payments.
Your information will be used for the assessment and administration
of payments and services. Your information may also be used within
Human Services, where you have provided consent or it is required or
authorised by law. Human Services may disclose your information to
Commonwealth Departments, other persons, bodies or agencies ONLY
where you have provided consent or it is required or authorised by law.
You can get more information about privacy by going to our website
humanservices.gov.au/privacy or requesting a copy of the full
privacy policy at any of our Service Centres.
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