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June 23, 2017

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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?

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?*

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.

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