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Application to Receive the Federal Government Rebate

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Application to Receive the Federal Government Rebate Powered By Docstoc
					                                                                                                 Application to Receive the
                            a subsidiary of
                                                                                                Federal Government Rebate
Please complete this form to receive the Federal Government Rebate on Private Health Insurance as a reduced premium. If at any stage you
wish to stop receiving the rebate as a reduced premium, you must notify Manchester Unity in writing.
Complete and sign all necessary sections. Please use a black pen and print in CAPITALS.


  1. Your details:

Manchester Unity Membership Number:


Title:	                         Given	Names:


Surname:


Residential	Address:	                                                                                                                                    State:	         Postcode:


Postal	Address:	(if	different	from	above)	                                                                                                               State:	         Postcode:


Home	Phone:	                                                        Day	Phone:	                                                      Mobile:
           –                                                                 –
Email:	



Register	for	online	services:          Yes	       No
Date	of	Birth:	                                                                                                                    Male:							Female:
            /              /

Are	you	covered	by	this	membership?	                     Yes	         No

If	no,	you	may	register	for	this	scheme	if	the	membership	is	ONLY	for	your	dependant	child	and	you	are	the	parent	of	that	child.


Are	all	the	people	on	your	membership	listed	on,	or	entitled	to,	a	Medicare	card?	                           Yes	       No

You	are	entitled	to	a	Medicare	card	if:	you	are	a	person	who	resides	in	Australia;	you	are	an	Australian	citizen;	a	holder	of	a	permanent	resident	visa;		
a	New	Zealand	citizen	or	in	some	cases	an	applicant	for	a	permanent	resident	visa.	For	enquiries	about	Medicare	eligibility	phone	13	20	11.	

Your	name	exactly	as	it	appears	on	your	Medicare	card:


Medicare	card	number:	                                     	    	          Expires:	
                                                                                       /	

Some	of	the	information	provided	on	this	form	will	be	used	for	the	purposes	of	registering	you	for	the	Federal	Government	Rebate	on	Private	Health	
Insurance.	Its	collection	is	authorised	by	law,	and	information	collected	will	be	disclosed	to	the	Department	of	Health	and	Ageing,	Medicare	Australia	
and	the	Australian	Taxation	Office.

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

Signature of Member
                                                                                                 Date
  7                                                                                         	                 /                /




For	help	completing	this	form	call	Member	Services	on	13	13	72.	Please	complete	all	relevant	sections	and	return	to	Manchester	Unity	via	FreeFax	or	Post.

W_REBATE_1209                                                                                                                                                                      PAGE	1/1

MANCHESTER	UNITY	AUSTRALIA	LTD	(ABN	99	087	648	771)	IS	A	REGISTERED	PRIvATE	HEALTH	INSURER	UNDER	THE	PRIvATE	HEALTH	INSURANCE	ACT	(2007)	AND	IS	A	REGISTERED	FRIENDLY	SOCIETY	UNDER	THE	LIFE	
INSURANCE	ACT	1995.		MANCHESTER	UNITY	AUSTRALIA	LTD	IS	A	WHOLLY	OWNED	SUBSIDIARY	OF	THE	HOSPITALS	CONTRIBUTION	FUND	OF	AUSTRALIA	LIMITED	(ABN	68	000	026	746).				                      1209


                               FREEFAX 1800 789 130 or POST: Manchester Unity, GPO Box 9964, Sydney NSW 2001

				
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Description: Application to Receive the Federal Government Rebate