To enable us to process your referral, please follow the instructions for one of the following options:

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1 We have received a referral that requests an utpatient appintment fr yu at Eastern Health. Frm the details that we have received we are nt able t establish if yu are entitled t public health care as we d nt have a Medicare details fr yu. If yu d have a current Medicare Card please Cmplete the attached Frm A: Outpatient Registratin and return it t Eastern Health within ne (1) week f receipt f this letter. This will enable us t make an appintment fr yu, and at yur first appintment yu will need t bring yur current Medicare card with yu. If yu d nt have a MEDICARE card please prceed as fllws: T enable us t prcess yur referral, please fllw the instructins fr ne f the fllwing ptins: Optin 1: If yu are a visitr t Australia(frm Belgium, Finland, Ireland, Italy (6 Mnths), Malta (6 Mnths), New Zealand, Nrway, Sweden, the Republic f Slvenia, The Netherlands and United Kingdm ) yu may be cvered by a reciprcal rights agreement, please: Cnfirm yur entitlement by calling Medicare n Cmplete the attached Frm A: Outpatient Registratin and return it t Eastern Health l within ne (1) week f receipt f this letter. This will enable us t make an appintment fr yu, and at yur first appintment yu will need t bring a clur cpy f yur passprt and entry visa t validate yur status. Optin 2: If yu can prvide prf that yu are an Asylum Seeker, yu will be prvided free necessary medical care including all services related t that care. Please: Ensure yu have supprting dcumentatin f yur status frm the Department f Immigratin and Citizenship r frm a recgnised asylum supprt agency such as the Red Crss. Yur dcumentatin must be prvided t the Patient Accunt Department (ask at the cashier ffice t cntact us) prir t yur appintment, the hspital will regard yu as nt eligible fr Medicare (Optin 3, belw, will then apply t yu) Cmplete the attached Frm A: Outpatient Registratin and return it t Eastern Health l within ne (1) week f receipt f this letter. This will enable us t make an appintment fr yu, and at yur first appintment yu will need t bring a clur cpy f yur passprt and entry visa t validate yur status and/r yur supprting dcumentatin. Optin 3: If yu are nt eligible fr Medicare yu will be required t pay fr all the csts related t yur maternity care and the csts f yur baby s care shuld yur baby require admissin r treatment. (See fllwing table fr csts.) These fees d nt include any prsthesis, discharge pharmaceuticals r special care nursery charges.

2 If yu are uninsured fr pregnancy care, the fixed fee fr maternity care is $14,400. This fee includes all medical, emergency, utpatient, inpatient, theatre, and dmiciliary services. Payable in three equal instalments f $4,800 prir t the birth. The first instalment is due prir t yur first utpatient appintment. The secnd instalment is payable by 28 weeks and the third and final instalment is payable tw weeks prir t estimated delivery r at delivery (if befre expected due delivery date). Alternatively yu may elect t receive a 10% discunt by paying in full the entire cst f yur maternity care prir t yur first appintment (meaning the cst will be $12,960). Cmplete the attached Frm B: Medicare Ineligible Outpatient Registratin and return it in the enclsed reply paid envelpe within ne (1) week f receipt f this letter. Maternity care fr UNINSURED patients cvers all medical, emergency, utpatient, inpatient, theatre, and dmiciliary care services 1 st Optin: Payable in three equal instalments prir t delivery first payment payable prir t first appintment 2 nd Optin: Payable in full prir t first appintment (incrprating 10% discunt) Rate per birth episde $14,400 $12,960 Nenate care INSURED & UNINSURED patients Overnight stay fr each baby in special care nursery Same day/overnight stay fr baby readmitted t General Ward fr treatment Medical fees including anaesthetic fees, prstheses & discharge pharmacy items Rate $1,300 per night $920/$1,300 per day/night Full cst per service If yu have private health insurance with an Australian Health Insurance fund yu must supply evidence that yu and yur baby will be fully cvered fr all services and a guarantee f payment frm yur insurance cmpany. Yur prenatal care will invlve a $350 charge fr yur initial cnsultatin and $260 fr each subsequent utpatient cnsultatin, (including midwife, dmiciliary care and fetal mnitring each) payable prir t yur appintment at the cashier ffice. Maternity Care fr INSURED patients Emergency Department attendance Outpatient visit exclusive f Pathlgy r Radilgy services Overnight stay prir t the birth/fr the birth/pst-birth perid per night Same day stay prir t birth Medical fees including anaesthetic fees, prstheses & pharmaceutical services Rate $440 per visit $350 initial/$260 subsequent $1,600 per night $920 per day Full cst per service

3 Optin 4: If yu n lnger require Eastern Health t prcess yur referral, and/r yu n lnger wish t cntinue yur planned care with Eastern Health please cntact the Patient Accunts Department n r immediately. Failure t respnd t any f the abve ptins within 7days will result in Eastern Health cancelling all registratin. Please nte: Yu must cntact yur GP t arrange rutine bld and urine tests, and week gestatin ultrasund as this is nt included in yur hspital care Fr any further assistance please call Patient Accunts n r Yurs sincerely Jan Brughtn Receivables Patient Accunts Manager Eastern Health Please cmplete and return bth frms t the fllwing: By Mail Patient Accunts Eastern Health P O Bx 94 Bx Hill VIC 3128 By

4 Frm A: Outpatient registratin Please cmplete all sectins f this frm and return t Eastern Health within ne week f date n letter. Patient Details Q1. Have yu ever attended Eastern Health befre? Yes N Q2. Are yu a permanent resident f Australia? Yes N Previus Name Used Title Mrs. Ms Miss Family Name: Lcal Address: Suburb: First Name: State: Pstcde: Gender: Date f Birth: Cuntry f Birth: Language spken: Mbile N.: Hme N.: Religin: Special Needs: D yu need an interpreter? YES NO Marital Status: Single Married Defact /Partner Separated Patients Indigenus State: Nne Abriginal Trres Strait Islander Bth Partner s Indigenus State: Nne Abriginal Trres Strait Islander Bth (Only answer if having a baby) Patient Cntact / Next f Kin Relatinship: Mbile N.: Hme N.: Health Insurance Details Medicare Number: Medicare expiry: Private Insurance Details: Yes N Insurance Cmpany: Health Fund Number: Level f Cver: Other Insurance Optins (if applicable) Health Care Card Number: Expiry: Pensin Card number: Expiry: DVA: Gld White Number: Expiry: Visit is related t: Wrk cver claim number: TAC Claim Number: (Please bring supprting dcumentatin t each visit) GP Details GP name: Phne N.: Address: Suburb: State: Pstcde: I cnfirm t the best f my knwledge this infrmatin prvided is accurate and cmplete NAME (PRINT): SIGNATURE: DATE: / /

5 Frm B: Medicare Ineligible Outpatient Registratin Please cmplete all sectins f this frm and return t The Eastern Health within ne week f date n letter. Patient Details Title Mrs Ms Miss Lcal Address: (N PO Bxes Allwed) Family Name: Suburb: First Name: State: Pstcde: Gender: Date f Birth: Cuntry f Birth: Language spken: Mbile N.: Hme N.: Religin: Special Needs: D yu need an interpreter? YES NO Marital Status: Single Married Defact /Partner Separated Passprt Number: Visa Type: Arrival Date: Expiry Date: Overseas Address: Patient Cntact / Next f Kin * Lcal (Australia) Relatinship: Mbile N.: Hme N.: * Overseas Phne N.: Cnfirmatin f Maternity Care at Eastern Health Q1. D yu wish t cntinue yur planned care at the Eastern Health? YES, please cmplete the remaining sectins f this frm What is yur expected date f delivery? d d / m m / / y y y / y NO, please cmplete the abve sectins f this frm and return it t the hspital within ne week Q2. Have yu ever attended Eastern Health befre? NO YES Previus Name Used Payment fr Maternity Services (select ne ptin - Nt applicable fr asylum seekers with dcumentatin) Optin 1: I am insured fr pregnancy care and agree t pay any shrtfall between the amunt charged by Eastern Health and benefits paid by my health insurance plicy Health Insurance Fund name: Plicy Number Optin 2: I agree t pay $12,960 prir t my first appintment Optin 3: I agree t pay $14,400 in three equal installments f $4,800 each, prir t my delivery and that the first installment is paid prir t my first appintment (NOTE: full fee must be paid if baby is due within 10 weeks) GP Details GP name: Phne N.: Address: Suburb: State: Pstcde: I cnfirm t the best f my knwledge this infrmatin prvided is accurate and cmplete NAME (PRINT): SIGNATURE: DATE: / /