Hospital Admission Voucher

Form ID
For providers
Hospitals & day procedure centres

A separate admission voucher (D0652B, may also be referred to as D652B) must be completed for each Hospital Admission.

If you are using an Apple computer and want to fill out your form electronically, please download the form and open it with Acrobat 7 or later.

How can I access this form?
Form (PDF or Word)