Consent to Bulk Bill

Submission of this form constitutes consent that I agree to the assignment of the Medicare benefit directly to the provider for me, as described on this page and processed by Neurology Network Melbourne at the time of my telehealth appointment.

Title/Salutation (required)

—Please choose an option—MsMrsMissMrMasterMxDrProfRevLadySirCaptLt

Your Name (required)

Date of Birth (required)

Do you consent to have your telehealth consultation Billed to Medicare on your behalf?

—Please choose an option—YesNo

Please leave this field empty.