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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.

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.

Name of private health fund

Health Fund Membership Number

Your full name as it appears on your Medicare card (required)

Family Name (required)

First Name (required)

Date of Birth - dd/mm/yyyyy (required)

Gender (required)

Male Female

Your Medicare Card Details Number (required)

Valid To (required)

Please enter dd/mm/yyyy (interim and reciprocal cards) or mm/yyyy for permanent residents

Permanent address

Line 1 (required)

Line 2

Suburb (required)

State (required)

Postcode (required)

Daytime Phone Number (required)

Postal address (if different to above)

Same as home

Yes

For more information

For more information about the Australian Government Rebate on Private Health Insurance, go to privatehealth.gov.au Questions about Medicare eligibility can be made at any Human Services’ Service Centre or by calling 132 011.

Note: Call charges apply – calls from mobile phones may be charged at a higher rate.

Applicants must nominate a rebate tier based on their estimated income for the financial year from the rebate tier below.

Tier	Single	Family

Date premium reduction to commence

Privacy Notice

Your information may be provided to the Australian Government Department of Human Services. The Department of Human Services uses this information for administering the Australian Government Rebate on private health insurance as a reduced premium. The collection of this information is permitted by the Privacy Act 1988. The Department of Human Services may disclose this information to other Commonwealth departments or agencies, anyone who you have agreed to have your information or other parties where the release is required or authorised by law (including for the purpose of research or conducting investigations).

You can get more information about the way in which the Department of Human Services will manage your personal information, including its privacy policy, at www.humanservices.gov.au/privacy.

Claimant’s 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 declarations.

Date of Declaration

AUSTRALIAN GOVERNMENT REBATE