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    Title/Salutation (required)

    Your Name (required)

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    Your Address (required)

    Your Postal Address if different (required)

    Your Email (required)

    Mobile phone number (required)

    Home phone number (mobile preferred)

    Occupation

    Referring Doctor (required)

    Referring Doctor Address

    Name of GP (if different from referring doctor)

    Address or Suburb of GP (if different from referring doctor)

    Who is responsible for account payment?

    Medicare Number (required)

    Medicare Ref Number (required)

    Medicare Exp Date MM/YY (required)

    Are your bank details registered with Medicare?

    Is this referral related to a WorkCover or TAC claim? (required)

    If "Yes" what is the TAC/WorkCover Claim Number?

    Private Health Insurer

    Private Health Number

    Are you on a Full Pension?

    NoYes

    Are you on a Part Pension?

    NoYes

    Pension Number

    Health Care Card Number

    I have read and accept the fee statement outlined on this page (required)

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    I will notify staff if correspondence regarding my personal and medical information should not be sent via email (required)

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    Privacy Policy

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    Doctor’s Fee Statement

    Dr Nicholas Crump

    Please Note: This practice does not Bulk Bill

    Consultation Item Numbers & Service Fees:

    Item 132: Complex Initial Consultation (45 mins)

    Standard Fee $480

    Full Pension $365; Medicare Rebate (approx) $240

    Item 110: Initial Consultation

    Standard Fee $375

    Full Pension $265; Medicare Rebate (approx) $137

    Item 133: Complex Review Consultation (20 mins)

    Standard Fee $255

    Full Pension $200; Medicare Rebate (approx) $120

    Item 116: Review Consultation

    Standard Fee $200

    Full Pension $150; Medicare Rebate (approx) $68

    Item 18377: Botox Injections for Migraine

    Standard Fee $265

    Full Pension $205; Medicare Rebate (approx) $110

    Item 11018: Nerve Conduction Study/EMG

    Standard Fee $410

    Full Pension $320; Medicare Rebate (approx) $200

    NB: Workcover/TAC accounts – it is the patient’s responsibility to supply written approval by a third party/insurer of acceptance of financial responsibility for their accounts.

     

    Workcover/TAC patients will be held responsible for the account in the absence of approval and/or payment.

     

    TAC Patients – Pre approval is required from TAC for any accident prior to 14th February 2018

    Please note that these fees are reviewed on July 1st each year. Patients with financial difficulties should bring their circumstances to the attention of the staff or the doctor. Accounts referred to a collection agent or solicitor will have all legal costs and commission added to the amount due.