EEG Patient Registration - Epilepsy Network Australia

Title/Salutation(Required)

Your name(Required)

Date of Birth(Required)

Your email address(Required)

Your Address(Required)

Medicare Number(Required)

Medicare Ref Number(Required)

Medicare Exp Date MM/YY(Required)

Do you identify as being Aboriginal or Torres Strait Islander origin?(Required)

Are your bank details registered with Medicare?

Mobile phone number(Required)

Home phone number (mobile preferred)

Occupation

Referring Doctor Name(Required)

Referring Doctor Address

Name of GP (if different from referring doctor)

Address or Suburb of GP (if different from referring doctor)

Who is responsible for account payment?

I have read and accept the fee statement outlined on this page(Required)

I have read and accept the privacy policy(Required)

I am happy for medical correspondence regarding my care to be transmitted via email(Required)

I will notify staff if correspondence regarding my personal and medical information should not be sent via email(Required)

If you have a tele-health consultation, and are eligible for bulk-billing, do you consent to assign your medicare rebate to the doctor?(Required)

Consent

Contact for approved research

Dear Epilepsy Network Australia patient,

The doctors at Epilepsy Network Australia are active in both local and International medical research in the field of epilepsy. New studies commence all the time and occasionally we are involved in recruiting patients for clinical trials.

You are treating specialists are up-to-date with current, local clinical studies and research trials that are recruiting and it may be that they identify you is a suitable candidate for participation.

We would like to contact you if your doctor thinks you would be eligible to participate in such a study. Examples of this include questionnaires, telephone interviews, physical therapies and occasional medical therapies.

This consent form is designed to indicate your willingness to be contacted regarding potential future studies, but does not imply that you consent to be involved with any study. You are able to withdraw consent from this process at any time by calling 03 7066 4607, or speaking with your doctor.

Click on this link to read and review our Privacy Policy.

Name

This field is for validation purposes and should be left unchanged.

Doctor’s Fee Statement

Please Note: This practice does not Bulk Bill with the exception of people who identify as Aboriginal or of Torres Strait Islander origin

Consultation Item Numbers & Service Fees:

Complex Initial Consultation (45 mins)

Standard Fee $495

Medicare Rebate (approx) $236

Initial Consultation

Standard Fee $370

Medicare Rebate (approx) $136

Complex Review Consultation (20 mins)

Standard Fee $235

Medicare Rebate (approx) $118

Review Consultation

Standard Fee $170

Medicare Rebate (approx) $67

Telephone Review Consultation

Standard Fee $110

Medicare Rebate (approx) $40

EEG

Standard Fee $350

Medicare Rebate (approx) $110

NB - Please note, we don't see patients with workcover or TAC Claims.

Cancellation policy:

Please note appointments cancelled with less than 48 Hours notice (excluding weekends) will be charged a cancellation fee of $200 for NEW appointments and $100 for review appointments.

Please note that these fees are reviewed on July 1st each year. Patients with financial difficulties should bring their circumstances to the attention of the staff or the doctor. Accounts referred to a collection agent or solicitor will have all legal costs and commission added to the amount due.