Applicant First name Title/Rank
Defence Health Limited
ABN 80 008 629 481 AFSL 313890
Address PO Box 7518 Melbourne VIC 8004
Freecall 1800 335 425
Facsimile 1300 665 096
Suburb State Postcode www.defencehealth.com.au
Daytime phone Email
A Health benefits claim form
PLEASE COMPLETE IN BLACK PEN AND IN BLOCK LETTERS WITHIN THE BOXES PROVIDED. ORIGINAL ACCOUNTS AND RECEIPTS MUST BE ATTACHED.
Given name and Date of Date of Type of Name of practitioner Account Name of school*
initial of patient birth service service (include practice suburb) Paid if aged 21 - 25
eg. Peter A 04/09/69 18/11/05 Physio Andrew Black - Brighton Yes/No Monash Uni
Benefits to dependants aged 21-25 are only payable to full-time students attending school, university or college.
B In-hospital medical claim
Please check with your doctor’s office as to whether the account is an Access Gap Cover claim or a standard medical gap claim.
If Access Gap Cover - send the claim form directly to us without going to Medicare. We will pay the combined Medicare and health fund benefit.
If a standard medical gap claim - submit the doctors account to Medicare first, then send the resulting Medicare Statement to Defence Health.
Name of hospital Admitted / / Discharged / /
Adding a new born baby? Daughter Son Given names DOB / /
• If you have already paid your health service provider your benefit will be remitted directly into your previously registered Direct Claims Payment
bank, building society or credit union account. You can register, check or alter your direct credit account online at www.defencehealth.com.au
or by calling us on 1800 335 425.
• A cheque to the provider will be drawn for any unpaid accounts.
• A cheque to the member will be drawn if you do not have a registered Direct Claims Payment bank, building society or credit union account.
• If you are an overseas Defence Force member please tick to have your benefit remitted into your pay through DEFPAC.
Are any of the services claimed related to an accident, illness or injury which has, or may, result in payment of compensation or
damages from another source eg. Workers Compensation, Transport Accident, Third Party or any other source? No Yes
If yes, please complete an accident questionnaire. You can download one from www.defencehealth.com.au or contact our member
service line on 1800 335 425 to have one posted to you.
* A HB CA 009 *
I declare that I have incurred the expenses in this claim and to the best of my knowledge, the information supplied is true and correct.
I authorise Defence Health Limited to obtain such information as is necessary from the provider to verify or audit this claim.