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Rebate Confirmation

Application to receive the Australian Government Rebate on Private Health Insurance as a reduced premium

All the people listed on the policy must be eligible to claim Medicare for you to receive the rebate as a reduced premium.
If at any stage you wish to nominate a new income tier or stop receiving the Australian Government Rebate as a reduced premium, you must notify your health fund as soon as possible.

Name of private health fund

Are you covered by this policy?

YesNo

(If No) Applicants not covered by the policy cannot claim the Australian Government Rebate on Private Health Insurance (excluding child only policies) and employers and trustees of organisations cannot claim the Australian Government rebate on Private Health Insurance on policies paid on behalf of employees.

Date premium reduction to commence

Your full name as it appears on your Medicare card

Your Medicare Card Details Number

Patient Ref No

Valid To

Home Address

Line 1

Line 2

Line 3

Suburb

State

Postcode

Postal Address

Same as home

Daytime Phone Number

Date of Birth

Sex

Provide details of all people covered on the policy (Do not include yourself)

Are all the people on the policy listed on a Medicare card or entitled to a Medicare Card?*

YesNo

You may be entitled to a Medicare card if you are:

a person who lives in Australia, and
an Australian citizen, or
a holder of a permanent resident Visa, or
a New Zealand citizen, or
an applicant for a permanent resident Visa.

Questions about Medicare eligibility can be made at any Human Services’ Service Centre or by calling 132 011.
or go to: https://www.humanservices.gov.au/customer/services/medicare/medicare-card
Note: Call charges apply – calls from mobile phones may be charged at a higher rate.

Income Tier

Declaration

I declare that:

the information I have provided in this form is complete and correct.

I understand that:

giving false or misleading information is a serious offence.

Please check this box to indicate you have read and understood the Declaration

Date of Declaration

Privacy Note

Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. 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.

You can get more information about the way in which the Department of Human Services will manage your personal information, including our privacy policy at www.humanservices.gov.au/privacy or by requesting a copy from the department.