Medicare Bulk Billing Assignment of Benefit

Please complete the following.

• This is a post-service (after session) agreement.

• The provider is Dr Jamie Marshall, Clinical Psychologist, PO Box 107 Coffs Harbour, NSW 2450. Medicare provider number is 454379CY.

• The session was conducted by telehealth.

• Medicare item number 91167 - Telehealth 50+ minutes delivered by a Clinical Psychologist.

• By agreeing to assign the Medicare benefit, I confirm that I am authorised to do so, and recognise that I will not be charged any further fee for this session.