Name: Medical Billing Experts
Address: 921-929 Kingsford Smith Drive, Eagle Farm, QLD, 4009, Australia
Telephone: 1300809484

Are you making payment on behalf of yourself or someone else?*
- Myself
- My Child
- My Spouse or Partner
- Someone Else

Patient's full name*
Patient's date of admission*
If you are not sure of the admission date, just enter today's date.
DD slash MM slash YYYY
Doctor*
Please enter the name of the doctor you are making your payment to.
Do you know your payment reference number?*
- Yes
- No
Payment reference number*
Patient's date of birth*
We require this information in lieu of your payment reference number.
DD slash MM slash YYYY

Gap Amount*
Please enter the gap fee payable. This is your out of pocket expense as indicated in the estimate we sent you.
Bank Fee
Price: $ 0.00
Total
$ 0.00
Informed Financial Consent*
The amount you are paying today is our estimate of your out-of-pocket costs. The bulk of the fee for this service will be paid directly to the provider from Medicare and your health fund. Your known gap estimate of fees was prepared with the understanding that you hold private health insurance, that your policy is up to date, and that you hold an adequate level of cover for the services that are to be provided. If for any reason your health fund rejects our claim, you will incur additional costs. Our estimate does not include hospital fees, or fees for services provided by any other medical practitioners involved in your care.
I understand