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This information is required to process your application or claim. Your information may be used by the department or given to other parties for the purposes of research investigation or where you have agreed or it is required or authorised by law. Number of Assignment of benefit form s included with this application 8 Name of health professional DB018. 1411 1 of 2 Reason for bulk bill claim adjustment Declaration 13 I claim Medicare benefits for the professional services the Give details why th ...

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