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Health Insurance Act 1973
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Administered by
Department of Health, Disability and Ageing
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C2020C00063 C111
01 January 2020
-
16 June 2020
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Part I—Preliminary
1 Short title
2 Commencement
3 Interpretation
3AAA Accreditation of podiatrists
3AAB Review by Administrative Appeals Tribunal
3AA Approved pathology practitioners to ensure proper supervision of pathology services
3B Meaning of medical entrepreneur
3BA Prescribed dental patients
3C Health service not specified in an item
3D Recognition as specialists of members of certain organisations on advice from the organisation
3DA Period of section 3D recognition
3DB Alternative method of recognition as a specialist or consultant physician
3DC Period of effect of determination
3E Recognition as consultant physicians etc. of certain medical practitioners
3EA Recognised Fellows of the Royal Australian College of General Practitioners
3EB Revocation of determinations
3F Vocationally registered general practitioners
3G Removal from Register
3GA Register of Approved Placements
3GB Removal from the Register
3H References to RACGP may be varied
4 General medical services table
4AAA Multiple general medical services
4AA Diagnostic imaging services table
4AB Multiple diagnostic imaging services
4A Pathology services table
4B Multiple pathology services
4BAA Conditional specification of services in table items
4BA Pathologist determinable services
4BB Prescribed pathology services
6 Certain persons in Australia to be treated as eligible persons etc.
6A Certain prescribed persons in Australia to be treated as eligible persons etc.
7 Agreement for reciprocal treatment of visitors to Australia and other countries
7A External Territories
7B Application of the Criminal Code
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Part II—Medicare benefits
8 Interpretation
8A Minister may determine registered family is FTB(A) family
9 Medicare benefits calculated by reference to fees
10 Entitlement to Medicare benefit
10AA Registered families
10AB Consequences of altered family composition
10AC Safety net—families
10ACA Extended safety net—families
10AD Safety net—individuals
10ADA Extended safety net—individuals
10AE Confirmation of family composition
10A Indexation
10B Determinations for subsections 10ACA(7A) and 10ADA(8A)
10C Evaluation of the caps measures
14 Medicare benefit not to exceed medical expenses incurred
15 Medicare benefit in respect of 2 or more operations
16 Administration of anaesthetic and assistance at operation
16A Medicare benefits in relation to pathology services
16B Medicare benefits in relation to R type diagnostic imaging services
16C Medicare benefits in relation to diagnostic imaging services rendered in contravention of State or Territory laws
16D Medicare benefits not payable for certain diagnostic imaging services: registration
16E Medicare benefit is payable once a suspension of a registration is lifted
16EA Medicare benefits not payable for certain diagnostic imaging services: accreditation
16F Medicare benefits not payable for certain radiation oncology services
16G Medicare benefit is payable once a suspension of a registration is lifted
17 Medicare benefits not payable in respect of certain medical expenses
18 Medicare benefit not payable where compensation etc. payable
19 Medicare benefit not payable in respect of certain professional services
19A Medicare benefit not payable in respect of services rendered in prescribed circumstances
19AA Medicare benefits not payable in respect of services rendered by certain medical practitioners
19AB Medicare benefits not payable in respect of services rendered by certain overseas trained doctors etc.
19ABA Medicare benefits not payable in respect of services rendered by doctors who breach certain contracts with the Commonwealth
19AC Reconsideration and review of decisions under subsection 19AB(3)
19B Medicare benefit not payable in respect of services rendered by disqualified practitioners
19C Medicare benefit not payable where medical practitioner not authorised to render service
19CA Review of decisions
19CB Offence in relation to a medical practitioner rendering an unauthorised service
19CC Offence in relation to a medical practitioner rendering a service covered by section 19AA, 19AB or 19ABA
19D Offences in relation to disqualification of practitioner
19DA Offence in relation to deregistered practitioner
19DB Offence where approval of premises as accredited pathology laboratory has been revoked
20 Persons entitled to medicare benefit
20A Assignment of Medicare benefit
20AA Security interest must not be created in medicare benefit
20AB Approved billing agents
20AC Revoking approvals of billing agents
20AD Review of decisions
20B Claims for medicare benefit
20BA Confirmation of referral to a consultant physician or specialist
20BB Confirmation of other referrals
21 Meaning of eligible midwife
21A Common form of undertaking by eligible midwife
21B Undertaking by eligible midwife
21C Review and effect of refusal by Minister to accept undertaking by eligible midwife
22 Common form of undertaking by eligible nurse practitioner
22A Undertaking by eligible nurse practitioner
22B Review and effect of refusal by Minister to accept undertaking by eligible nurse practitioner
23A Common form of undertaking by optometrist
23B Undertaking by optometrist
23D Date of effect of refusal by Minister to accept undertaking by optometrist
23DAA Review of refusal by Minister to accept undertaking by optometrist
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Part IIA—Special provisions relating to pathology
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Division 1—Preliminary
23DA Interpretation
23DB Forms of undertaking
23DBA Categories of eligible pathology laboratories
Division 2—Approved pathology practitioners and approved pathology authorities
23DC Giving an acceptance of approved pathology practitioner undertaking
23DD Period of effect of approved pathology practitioner undertaking
23DDA Backdated undertakings
23DE Approved pathology practitioner may terminate undertaking
23DF Giving an acceptance of approved pathology authority undertaking
23DG Period of effect of approved pathology authority undertaking
23DGA Backdated undertakings
23DH Approved pathology authority may terminate undertaking
23DK Request forms and confirmation forms
23DKA Other records of pathology services
Division 3—Breaches of undertakings and initiation of excessive pathology services
23DL Breaches of undertakings by approved pathology practitioners and approved pathology authorities
Division 4—Accredited pathology laboratories
23DN Accredited pathology laboratories
23DNA Determination of principles for accreditation as pathology laboratory or revocation or variation of accreditation
23DNAAA Backdated approvals
Division 4A—Specimen collection centres
23DNBA Grant of approval for collection centre
23DNBB Identification number
23DNG Revocation of approval
23DNH Cancellation of approval
23DNI Partial refund of tax for early cancellation of approval
23DNJ Inspection of specimen collection centres
23DNK Notice that specimen collection centre is approved
23DNL Offence in relation to unapproved specimen collection centres
Division 5—Miscellaneous
23DO Review of decisions
23DP Offences in relation to request forms and confirmation forms
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Part IIB—Special provisions relating to diagnostic imaging services
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Division 1—Requests for, and records relating to, diagnostic imaging services
23DQ Form etc. of requests
23DR Retention of requests etc.
23DS Other records of diagnostic imaging services
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Division 1A—Continuing medical education and quality assurance in respect of providers of diagnostic imaging services
23DSA Definitions
23DSB Approval of program
23DSC Registration of participants in approved program
23DSD Deregistration
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Division 2—Remote area exemptions
23DT Interpretation
23DU Remote areas
23DV Application for remote area exemption
23DW Request for further information
23DX Grant of remote area exemption—provision of services where requirements of subsection 16B(1) are not met
23DXA Grant of remote area exemption—stationing diagnostic imaging equipment and employees at the premises of another practitioner
23DY Restrictions on remote area exemptions under section 23DX
23DYA Restrictions on remote area exemptions under section 23DXA
23DZ Refusal of application
23DZA Commencement and duration of remote area exemption
23DZB Renewal of remote area exemption
23DZC Revocation of remote area exemption
23DZD Review of decisions
23DZE Statements to accompany notification of decisions
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Division 4—Diagnostic Imaging Register
23DZK Diagnostic Imaging Register
23DZL What is a base for mobile diagnostic imaging equipment?
23DZM What are diagnostic imaging premises?
23DZN Who may apply for registration?
23DZO Who is a proprietor?
23DZP Application procedure
23DZQ Registration
23DZR Primary information
23DZS Register may be maintained electronically
23DZT Extract of the Register to be made available on request
23DZU Minister may publish an extract of the Register on the internet
23DZV Proprietors to notify the Minister of changes to primary information
23DZW Minister may request further information
23DZX Suspension for failure to comply with a request
23DZY Cancellation for failure to provide information within 3 months after the response period
23DZZ Cancellation at the request of the proprietor
23DZZA Cancellation on other grounds
23DZZB Cancellation to be noted on the Register
23DZZC Limits on registration after cancellation under section 23DZY or 23DZZA
23DZZD Minister must invite submissions before cancelling registration
23DZZE Application to Administrative Appeals Tribunal for review of a decision to cancel registration
23DZZF Proprietor of unregistered premises must notify patients that medicare benefit not payable
23DZZG Proprietor of unregistered base must notify patients that medicare benefit not payable
23DZZH Debt recovery where proprietor fails to inform patient that premises or base not registered
23DZZI Application of this Division to partnerships
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Division 5—Diagnostic imaging accreditation
23DZZIAA Diagnostic imaging accreditation
23DZZIAB Diagnostic Imaging Register to include accreditation status
23DZZIAC Reconsideration of accreditation decisions
23DZZIAD Reconsideration by Minister of accreditation decisions
23DZZIAE Proprietor of unaccredited premises or base must notify patients that medicare benefit not payable
23DZZIAF Debt recovery if proprietor fails to inform patient that premises or base not accredited
23DZZIAG Application of this Division to partnerships
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Part IIBA—Prohibited practices in relation to pathology services and diagnostic imaging services
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Division 1—Preliminary
23DZZIA Objects of Part
23DZZIB Simplified outline
23DZZIC Crown to be bound
23DZZID Definitions
23DZZIE Meaning of requester and provider
23DZZIF Meaning of permitted benefit
23DZZIG Ministerial determinations of permitted benefits
23DZZIH Establishing whether an executive officer took reasonable steps to prevent commission of offence or contravention of civil penalty
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Division 2—Civil penalty provisions involving requesters, providers and connected persons
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Subdivision A—Preliminary
23DZZII Simplified outline
23DZZIJ Meaning of connected
Subdivision B—Civil penalty provisions
23DZZIK Requester civil penalty provisions—asking for or accepting prohibited benefits
23DZZIL Provider civil penalty provisions—offering or providing prohibited benefits
23DZZIM Provider civil penalty provisions—making threats
23DZZIN Application of this Division to an executive officer of a body corporate
Division 3—Offences involving requesters, providers and others
23DZZIO Simplified outline
23DZZIP Extended geographical jurisdiction—category A
23DZZIQ Requester offences—asking for or accepting prohibited benefits
23DZZIR General and provider offences—offering or providing prohibited benefits
23DZZIS General and provider offences—making threats
23DZZIT Application of this Division to an executive officer of a body corporate
23DZZIU Division not limited by Division 2
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Part IIC—Radiation Oncology Register
23DZZJ Radiation Oncology Register
23DZZK What is a base for mobile radiation oncology equipment?
23DZZL What are radiation oncology premises?
23DZZM Who may apply for registration?
23DZZN Who is a proprietor?
23DZZO Application procedure
23DZZP Registration
23DZZQ Primary information
23DZZR Register may be maintained electronically
23DZZS Extract of the Register to be made available on request
23DZZT Minister may publish an extract of the Register on the internet
23DZZU Proprietors to notify the Minister of changes to primary information
23DZZV Minister may request further information
23DZZW Suspension for failure to comply with a request
23DZZX Cancellation for failure to provide information within 3 months after the response period
23DZZY Cancellation at the request of the proprietor
23DZZZ Cancellation on other grounds
23DZZZA Cancellation to be noted on the Register
23DZZZB Limits on registration after cancellation under section 23DZZX or 23DZZZ
23DZZZC Minister must invite submissions before cancelling registration
23DZZZD Application to Administrative Appeals Tribunal for review of a decision to cancel registration
23DZZZE Proprietor of unregistered premises must notify patients that medicare benefit not payable
23DZZZF Proprietor of unregistered base must notify patients that medicare benefit not payable
23DZZZG Debt recovery where proprietor fails to inform patient that premises or base not registered
23DZZZH Application of this Part to partnerships
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Part IV—Health program grants
39 Interpretation
40 Approval of organizations
41 Approval of health services
41A Approval of health service development projects
42 Entitlement to health program grant
42A Entitlement to grant in respect of approved project
42B Grants in respect of certain payments made by approved organizations
43 Conditions of payment of grants
45 Claims for grants
46 Advances
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Part IVAA—Payments relating to the former Health and Hospitals Fund
46AA Payments relating to the former Health and Hospitals Fund
46AB Terms and conditions
46AC Appropriation
46AD Constitutional basis
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Part V—Committees
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Division 2—Medicare Benefits Advisory Committee
65 Interpretation
66 Medicare Benefits Advisory Committee
67 Functions of Committee
68 Election of Chairperson and Deputy Chairperson
69 Exercise of powers and functions of Chairperson by Deputy Chairperson
70 Appointment of person to act in place of member
71 Termination of appointment
72 Resignation of members
73 Appointment to vacant office
74 Remuneration and allowances
75 Meetings of Committee
76 Proceedings at meetings
77 Committee may inform itself in any manner
78 Chairperson may engage consultants
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Division 4—Other Committees
79 Other Committees
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Part VA—National Rural Health Commissioner
79AA Simplified outline of this Part
79AB National Rural Health Commissioner
79AC Functions of the National Rural Health Commissioner
79AD Appointment
79AE Acting appointments
79AF Terms and conditions
79AG Remuneration
79AH Leave of absence
79AI Outside employment
79AJ Resignation
79AK Termination of appointment
79AL Disclosure of interests
79AM Annual report
79AN Minister may give directions to the National Rural Health Commissioner
79AO Assistance from APS employees
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Part VAA—The Professional Services Review Scheme
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Division 1—Preliminary
79A Object of this Part
80 Main features of the Professional Services Review Scheme
80A Additional operation of this Part
81 Definitions
82 Definitions of inappropriate practice
82A Meaning of prescribed pattern of services
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Division 2—The Director of Professional Services Review and the Professional Services Review Panel
83 The Director of Professional Services Review
84 The Professional Services Review Panel
85 Deputy Directors of Professional Services Review
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Division 3—Role of Chief Executive Medicare
86 Requests by Chief Executive Medicare to Director to review provision of services
87 Chief Executive Medicare must notify person of request
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Division 3A—Review by Director
88 Director may request further information
88A Director must decide whether to review
88B Scope of Director’s review
89 When Director must review
89A Director may refer material to Chief Executive Medicare if certain offences or civil contraventions are suspected
89B Power of Director to require the production of documents or the giving of information
89C Director’s action following review
90 Director may consult on decisions
91 Decision to take no further action
92 Agreement entered into between Director and person under review
92A If agreement is not ratified
93 Referral to a Committee
94 Director taken to have made a decision after 12 months
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Division 4—Professional Services Review Committees
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Subdivision A—Constitution of Committees
95 Constitution of Committees
96 Challenging appointments to Committees
96A If Committee members are unavailable
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Subdivision B—Proceedings of Committees
97 Meetings
98 Conduct of meetings
99 Other procedural matters relating to meetings
101 Hearings
102 Notice of hearings
103 Rights of persons under review at hearings
104 Consequences of failing to appear, give evidence or answer a question when required
105 Disqualification for failing to appear, give evidence or answer a question when required
105A Power of Committee to require the production of documents or the giving of information
106 Conduct of hearings
106A Evidence at hearings
106B Summons to give evidence etc.
106C Allowances for witnesses at hearings
106D Failure to attend
106E Refusal to be sworn or to answer questions
106EA Contempt of Committee
106F Protection of Committee members, representatives and witnesses at hearings
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Subdivision C—Action to be taken by Committees
106G Application of Subdivision
106GA Notification by Director or Committee that proper investigation is impossible
106H Committee findings, scope of investigation etc.
106J Committee may request Director’s review
106K Committee may have regard to samples of services
106KB Generic findings of inappropriate practice
106KC Notification by Committee to Director of matters of concern to profession
106KD Preparation of draft report
106KE Draft report contains no finding of inappropriate practice
106L Final report of Committee
106M Referral of matter to a regulatory body to be mentioned in Committee’s report
106N Committee may refer material to Chief Executive Medicare if certain offences or civil contraventions are suspected
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Division 5—Determining Authority
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Subdivision A—Establishment etc. of the Determining Authority
106Q The Determining Authority
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Subdivision B—Ratification of agreements by the Determining Authority
106QA Application of Subdivision
106QB Notification by Director or Authority that action in agreement cannot take effect
106R Authority must ratify or refuse to ratify agreement
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Subdivision C—Determinations by the Determining Authority
106RA Application of Subdivision
106RB Notification by Director or Authority that proper draft or final determination is impossible
106S Director may give Determining Authority information
106SA Authority to invite submissions before making a draft determination
106T Draft determination
106TA Final determination
106TB Time for doing act affected if court order operates
106U Content of draft and final determinations
106UAA Referral of matter by Determining Authority to a regulatory body not to be taken into account by the Authority in making draft or final determinations
106UA Notification of final determination before it takes effect
106V When final determinations take effect
106W Notification of final determination
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Division 5A—Referral of professional issues to regulatory and other bodies
106XA Significant threat to life or health
106XB Non compliance by a practitioner with professional standards
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Division 6—Provisions relating to the Director, Panel members, staff and consultants, the Determining Authority and the provision of services to a Committee or the Authority
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Subdivision A—The Director
106Y Term of office
106Z Director’s terms and conditions of appointment
106ZA Outside employment
106ZB Leave of absence
106ZC Resignation
106ZD Termination of the Director’s appointment
106ZE Acting appointments
106ZF Remuneration and allowances
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Subdivision B—Panel members
106ZG Term of office
106ZH Panel member’s terms and conditions of appointment
106ZI Outside employment
106ZJ Resignation
106ZK Termination of a Panel member’s appointment
106ZL Remuneration and allowances
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Subdivision C—Staff and consultants
106ZM Staff
106ZN Arrangements with other Commonwealth bodies
106ZP Engagement of consultants
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Subdivision D—Provisions relating to Determining Authority
106ZPA Constitution of Determining Authority
106ZPB Appointment of members of the Authority
106ZPC Term of office
106ZPD Terms and conditions of appointment
106ZPE Outside employment
106ZPF Resignation
106ZPG Termination of appointment
106ZPH Acting appointments
106ZPI Remuneration and allowances
106ZPJ Protection of members of the Authority
106ZPK Meetings of the Determining Authority
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Subdivision E—Provision of services to a Committee and the Determining Authority
106ZPL Director to arrange for provision of services
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Division 6A—Application of the finance law
106ZPLA Application of the finance law
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Division 7—Miscellaneous
106ZPM Failure of person under review to produce documents or give information
106ZPN Failure by person other than person under review to produce documents or give information
106ZPO False or misleading answers
106ZPP False or misleading documents
106ZPQ No privilege against self incrimination
106ZPR Publication of particulars of reports and determinations
106ZQ Annual report
106ZR Disclosure of Committee deliberations etc.
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Part VB—Medicare Participation Review Committees
124B Interpretation
124BA Application of Part to providers who are not practitioners
124C Chairpersons
124D Chairperson etc. to be notified if practitioner convicted of relevant offence or civil contravention
124E Chairperson to establish Medicare Participation Review Committee
124EA Membership of Committees
124EB Qualification of members
124EC Provision of information to the person in relation to whom a Committee is convened
124F Determinations in relation to relevant offences and relevant civil contraventions
124FA Committee may add parties to proceedings in relation to breach of undertaking by approved pathology practitioner or approved pathology authority
124FB Determinations in relation to breach of undertaking by approved pathology practitioner
124FC Determinations in relation to breach of undertaking by approved pathology authority
124FD Committee may be established and proceedings may continue after undertaking ceases to be in force
124FE Committee may add parties to proceedings in relation to pathology and diagnostic imaging offences and contraventions
124FF Determinations in relation to pathology and diagnostic imaging offences and contraventions
124G Hearings
124H Guidelines relating to making a determination
124J Procedure of hearings
124K Hearings to be in public except in special circumstances
124L Summons to give evidence etc.
124M Refusal to be sworn etc.
124N Protection of members of Committees etc.
124P Contempt
124Q Chairperson to give notice of determinations by Committee
124R Review by Administrative Appeals Tribunal
124S Giving effect to determinations
124T Chairperson to abolish Committee
124U Fees and allowances
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Part VC—Quality assurance confidentiality
124V Object of this Part
124W Interpretation
124X Minister may declare quality assurance activity to be an activity to which this Part applies
124Y Information about declared quality assurance activity not to be disclosed
124Z Minister may authorise disclosure of information about a serious offence
124ZB Immunity from suit of members of assessment or evaluation committees
124ZC This Part is to complement corresponding State and Territory laws
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Part VD—Bonded Medical Program
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Division 1—Bonded Medical Program
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Subdivision A—Introduction
124ZD Bonded Medical Program
124ZE Bonded participants
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Subdivision B—Conditions of Bonded Medical Program
124ZF Return of service obligation
124ZG Conditions of Bonded Medical Program
124ZH Breach of condition of Bonded Medical Program—repayment of education costs
124ZJ Breach of condition of Bonded Medical Program—medicare benefits not payable
124ZK Breach of condition of Bonded Medical Program—administrative penalty
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Subdivision C—Review of decisions
124ZL Application for review
124ZM Notice of decision on review
124ZN Review by Administrative Appeals Tribunal
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Subdivision D—Withdrawal from Bonded Medical Program
124ZP Withdrawal from Bonded Medical Program
124ZQ Consequences of withdrawal
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Subdivision E—Information sharing
124ZR Authorised collection, use and disclosure
124ZS Interaction with the Privacy Act 1988
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Subdivision F—Bonded Medical Program rules
124ZT Bonded Medical Program rules
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Division 2—Transitional arrangements
124ZU Opt in process for participating in the Bonded Medical Program
124ZV Effect of opting in to the Bonded Medical Program—BMP participants
124ZW Effect of opting in to the Bonded Medical Program—MRBS participants
Part VI—Finance
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Part VIA—Civil penalties
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Division 1—Obtaining an order for a civil penalty
125A Federal Court may order person to pay pecuniary penalty for contravening civil penalty provision
125B What is a civil penalty provision?
125C Persons involved in contravening civil penalty provision
125D Recovery of a pecuniary penalty
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Division 2—Civil penalty proceedings and criminal proceedings
125E Civil proceedings after criminal proceedings
125F Criminal proceedings during civil proceedings
125G Criminal proceedings after civil proceedings
125H Evidence given in proceedings for civil penalty not admissible in criminal proceedings
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Part VII—Miscellaneous
126 Prohibition of certain medical insurance
127 Assignor of medicare benefit to be given copy of assignment etc.
128 Offences in relation to returns
128A False statements relating to medicare benefits etc.
128B Knowingly making false statements relating to medicare benefits etc.
128C Charging of fees for provision of public hospital services to public patients
129 False statements etc.
129AA Private hospitals—bribery
129AAB Offences against 2 or more provisions
129AAC Statements inadmissible as evidence
129AAD Notice to produce documents
129AADA Requirement to keep documents relating to notice to produce
129AAE Civil penalty—failure to comply with requirement in notice
129AAF Self incrimination etc.
129AAG Chief Executive Medicare or Departmental employee may deal with documents etc. produced
129AAH Notice of decision: no amount recoverable because amounts paid substantiated etc.
129AAI Notice of decision: amounts recoverable
129AAJ Review of decisions to claim amounts as debts
129AC Recovery of amounts overpaid etc. and administrative penalties
129ACA Shared debt determinations
129ACB Review of decisions relating to shared debt determinations
129AD Recovery of certain determined amounts
129AE Recovery of amounts paid in respect of certain diagnostic imaging services
129AEA Liability for administrative penalty
129AEB Amount of administrative penalty
129AEC Notice of administrative penalty and review of assessments
129AECA Power to obtain information relating to a debt
129AED Waiver and repayment of certain debts arising under the Chronic Disease Dental Scheme
129AEE Notice of decision to waive, or not to waive, a debt
129AEF Recoverable amounts may be set off
129AEG Garnishee notices
129AEH Failure to comply with garnishee notice
129AF State and Territory authorities to be notified of contraventions of certain laws
129A Special arrangements for optometrical services
130 Officers to observe secrecy
130AA Prosecution of offences
130G Evidence
130H Exceptions etc. to civil penalty provisions—burden of proof
130J Obligations not affected by State or Territory laws
131 Delegation
132 Evidence
132A Regulations relating to the manner of patient referrals
133 Regulations
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Endnotes
Endnote 1—About the endnotes
Endnote 2—Abbreviation key
Endnote 3—Legislation history
Endnote 4—Amendment history
