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The Queensland Government is in a caretaker period until after the state election. Minimal updates will be made to this site until after the election results are declared.

Patient registration (Form A)

Patient Travel Subsidy Scheme (PTSS)

Patient registration (Form A)

Section A

(patient or guardian / carer to complete)

Date of birth (DD/MM/YY)
(If different from residential address)
(or landline, if mobile not available)
Are you of Aboriginal and / or Torres Strait Islander origin?
(if different form patient)
(or landline, if mobile not available)
How would you like us to contact you? (You may select more than one option)
Section B

(patient or guardian / carer to complete)

A Medicare card number is required to be eligible for PTSS

Expiry date * (MM / YY)
Please tick if an of the following apply to you:
Expiry date * (DD /MM / YY)
(e.g. gold)
Expiry date * (DD / MM / YY)
Expiry date (DD / MM / YY)
Expiry date * (DD / MM / YY)
Section C

(patient or guardian / carer to complete)

The information provided is true and accurate at the time of application. I give my permission for Hospital and Health Service staff to obtain information about my / my child's / my ward's medical condition for the purpose of administering my application and to disclose relevant information, including a copy of this form, to approved travel / accommodation providers for the purpose of administration of the Patient Travel Subsidy Scheme (PTSS). I understand that I must keep copies of receipts / invoices for accommodation and transport, and may be asked to provide these to Hospital and Health Service staff.

(if 18 years or over ) or Guardian / Carer (if under 18 years)
Date * (DD / MM / YY)
(if applicable)
Hospital and Health Service use only
Proof of residency sighted /provided (e.g QLD licence, electricity / gas bill, other acceptable documents)?
Concession card(s) sighted /provided?
Date (DD /MM /YY)