Consent to release of Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) claims information by Services Australia to the Cancer Council Victoria for the purposes of the Australian Breakthrough Cancer Study.

Important Information

Please read the Participant Information Sheet before completing the Consent Form below. A copy of the Consent Form is also available. Complete this form to request the release of your personal Medicare claims information and your PBS claims information to the Australian Breakthrough Cancer Study. Incomplete forms may result in the study not being provided with your information

Rights and Privacy

I understand that:

• my MBS and PBS information will be disclosed by Services Australia for the purposes of the study
• the results of this research may be published in articles or journals
• my name will never be disclosed by Services Australia, used in the study or published
• my participation in the study is completely voluntary
• I can withdraw my participation in the study at any time (refer to participant information sheet and withdrawal of consent form) and I do not have to provide a reason for my withdrawal
• I understand the information provided to me about the study I am participating in
• I have been given the opportunity to ask questions, and any questions I have asked have been answered to my satisfaction

Consent

Do you consent to the disclosure by Services Australia of my MBS and PBS information to researchers for the purposes of the study?

 Yes  No

PARTICIPANT DETAILS

1. Mr  Mrs  Miss  Ms  Other 

Family name: _________ First given name: _________

Other given name (s): _________

Date of birth: ___ /____/_____ DD / MM / YYYY

2. Medicare card number: _________ (Ref Number) ____

3. Postal address: _________

Permanent address (if different to above): _________

AUTHORISATION

4. I authorise Services Australia to provide my:

• Medicare claims history OR
• PBS claims history OR
• Medicare & PBS claims history

For the period* 01/ 01/2020 to: 31/12/2035 to the Australian Breakthrough Cancer Study.

Date range is to be completed prior to or at the time of signing the consent form.

*Note: As Services Australia can only extract 4.5 years of data (prior to the date of extraction), the consent period above may result in multiple
extractions.

 If in the event that I pass away during the study period, I consent to Services Australia providing my claims
information to the study.

DECLARATION

I declare that the information on this form is true and correct.

5. Signed: _________ (participant’s signature) Dated: ___ /____/_____ DD / MM / YYYY

A sample of the information that may be included in your Medicare claims history:

A sample of the information that may be included in your PBS claims history:

Privacy and your personal information

The privacy and security of your personal information is important to us, and is protected by law.  We need to collect this information so we can process your applications and payments, and provide services to you.  We only share your information with other parties where you have agreed, or where the law allows or requires it.  For more information, go to servicesaustralia.gov.au/privacy