Online Members Services

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Rebate Confirmation

All 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 stop claiming the 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

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

Family Name

Given Name

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

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

YesNo

You are entitled to Medicare if:

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

Any enquiries about Medicare eligibility can be made at any Department of Human Services service centre or by phoning 132 011 for the cost of a local call.

Level of Rebate

Declaration

I declare that the Information I have provided is correct. I understand that there are penalties for giving false or misleading information.

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 for a Social Security, Family Assistance, Medicare, Child Support and CRS purpose, depending on the service or payment concerned. This information may be required by law or collected voluntarily when you apply for services or payments.

Your information is used for the assessment and administration of payments and services and may also be used within Human Services, or disclosed to other parties or agencies, where you have provided consent or it is required or authorised by law.

You can get more information about privacy by going to our website humanservices.gov.au/privacy or requesting a copy of the full privacy policy at one of our Service Centres.

Online Member Services

Note:

Rebate Confirmation

Home Address

Postal Address

Declaration

Privacy Note