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Tax invoice number (top right of invoice)
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Tax invoice number
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Tax invoice number
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Tax invoice number
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Patient first name
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Patient last name
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Date of Birth (DD)
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(MM)
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(YYYY)
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Contact telephone number
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Email
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Please tell us why you may not be liable for this invoice?
I have Motor Vehicle Accident Claim Information
I have Workplace Injury Claim Information
I have Private Health Insurance Claim Information
I have a DVA Concession Card
I have a Pension or Healthcare Card
I have Ambulance Victoria Membership
I have Interstate Ambulance Membership
I have Other Concession
TAC claim number
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Employer’s name
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Employer’s address line 1
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Employer’s address line 2
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City
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State
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Postcode
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Employer’s phone number
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Workcover claim number
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Workcover insurer
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Name of private health fund
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Claim number
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DVA card type
Gold Card
White Card
DVA Pension
DVA file number
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Patient’s CRN
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Primary cardholders’ CRN
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Primary cardholder first name
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Primary cardholder last name
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Ambulance Victoria member number
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Details of Entitlement – max 300 characters
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Details of Entitlement – max 300 characters
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Please provide any other information – max 2500 characters
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