19Application for safety net concession card

#### 19 Application for safety net concession card (1) For the purposes of paragraph 84DA(3)(b) of the Act, the following particulars are prescribed in relation to an application under subsection 84DA(1) or (2) of the Act: (a) the given name and surname of the applicant; (b) the residential address of the applicant; (c) the given name and surname of each person who is a member of the applicant’s family; (d) the relationship of each person referred to in paragraph (c) to the applicant; (e) the date on which the application is made; (f) the medicare number of the applicant. (2) For the purposes of paragraph 84DA(3)(b) of the Act, the following documents are prescribed in relation to an application under subsection 84DA(1) or (2) of the Act: (a) record forms issued to the applicant or to a member of the applicant’s family that: (i) record the value for safety net purposes of the pharmaceutical benefits, repatriation pharmaceutical benefits and out‑patient medication supplied to the applicant, or to a member of the applicant’s family, during the relevant entitlement period to which the application relates; and (ii) include a statement signed by the applicant declaring that the pharmaceutical benefits, repatriation pharmaceutical benefits and out‑patient medication recorded in the form were so supplied; (b) in respect of any other pharmaceutical benefit, repatriation pharmaceutical benefit or out‑patient medication so supplied, any document that establishes the value for safety net purposes of the pharmaceutical benefit, repatriation pharmaceutical benefit or out‑patient medication.