Application Form July 2014

Transcription

1 Application Form July I wish to (please tick) Join GMHBA Transfer from an existing GMHBA membership Change my cover GMHBA member number (existing members only) Cover or change of cover to commence from / / Cover does not commence until payment is received 2. Type of cover Single Family/couple Single parents 3. My details Member name Member number Address Suburb/city State Postcode Postal address (if different) Suburb/city Postcode Date of birth Sex Male Female Phone Mobile Fax address Yes Yes No I agree that GMHBA can communicate with me about my membership and my transactions with the fund using my address. I would like to receive the Great Health magazine, as well as invitations to member events, special offers and preventative health information from GMHBA. Please keep the Important Information Guide with your other GMHBA documents 4. Partner authority (optional for applicant to sign) I authorise the person identified as my partner/spouse on the application form to make changes to this membership, including varying the level of cover. Signed Date / / 5. Other people to be covered I confirm all people covered under my GMHBA membership are citizens or permanent residents of Australia who have full Medicare eligibility. Note: Children under 21 are covered under family memberships. Children over 21 and under 25 are covered if they are single and undertaking a full-time apprenticeship, full-time traineeship or full-time study at eligible educational institutions (please list below). (include surname if different to applicant) Relationship Date of birth M/F Given name / / Educational institution Given name / / Educational institution Given name / / Educational institution

2 Hospital Gold Hospital Gap Saver With Pregnancy No Pregnancy Level 0 (nil excess) PGHO PGNO PGH1 PGN1 PGH2 PGN2 Gold Hospital With Pregnancy No Pregnancy Level 0 (nil excess) GH0 GN0 GH1 GN1 GH2 GN2 Silver Hospital Level 0 (nil excess) SH0 SH1 SH2 Bronze Hospital Level 0 (nil excess) BH0 BH1 BH2 FIT Packages FIT Ultra Package XMa1Ma8 XMa2Ma8 FIT Top Package XMa1Mi8 XMa2Mi8 FIT Standard Package XBa1Mi8 XBa2Mi8 FIT Entry Package XBa100B XBa200B Extras Set benefits Percentage back Gold Extras GS G75 Silver Extras SS S65 Bronze Extras BS B55

3 6. Transferring from another health fund Health fund Cover name Member number Date joined / / Date paid to / / If you are transferring from another health fund, please attach a transfer certification form. Or, you can complete the attached Transfer Certificate Request form if you want GMHBA to terminate your membership and request a transfer certificate on your behalf. 7. Direct credit of claims benefits Please direct credit my benefits on paid account into the bank/building society/credit union account nominated below BSB number - Account number Name(s) the account is held in Bank name Branch If you are unsure of the BSB number, please contact the bank where the account is held 8. Method of payment Direct debit form my bank/building society/credit union (please complete Direct Debit Request form) Automatic payment from credit card (please complete Credit Card Authorisation form) Cash, cheque, BPay or BillPay each Monthly Quarterly Half-yearly Yearly Payroll deduction Employer Call us on to find out if this facility is avaliable 9. Privacy Prior to signing and submitting this Application Form, you must: - read the latest version of the GMHBA Health Insurance Privacy Statement; and - ensure any spouse/partner and adult dependent children who are to be covered by your GMHBA Health Insurance membership are aware of and consent to how their personal (including sensitive) information is handled by in accordance with our Privacy Statement. I declare that I, as well as all other adult persons to be covered by my GMHBA Health Insurance membership, have read, and consent to the collection, use and disclosure of our personal (including sensitive) information in accordance with the GMHBA Health Insurance Privacy Statement. 10. Declaration (applicant to sign) The signing of this application and the payment of any premium shall constitute an acceptance of the above privacy declaration and conditions laid down by the regulations in force at this time or as may be amended from time to time. I understand proof of identity including age may be required to confirm the details of persons listed on this application, the rulings regarding pre-existing conditions/illness, waiting periods and the conditions of membership. I declare the above statements/information to be true and correct. Signed Date / /

4 Application to receive or change the Australian Government Rebate on Private Health Insurance as a reduced premium Complete this registration form and lodge it with GMHBA Health Insurance to receive the Australian Government Rebate on Private Health Insurance. - All the people listed on the policy must be eligible to claim Medicare for you to receive the rebate as a reduced contribution. - If at any stage you wish to stop receiving the Australian Government Rebate on Private Health Insurance as a reduced premium, you must notify GMHBA Health Insurance as soon as possible. - 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 issuing the policy to which this application relates: GMHBA Health Insurance Membership number: Are you covered by this policy? Yes No Date contribution reduction commenced: / / Please nominate your rebate tier (refer to the GMHBA Important Information Guide for more detail): Your age Base Income Tier Income Tier 1 Income Tier 2 Income Tier 3 Singles $90,000 or less $90,001 - $105,000 $105,001 - $140,000 $140,001 or more Families/Couples $180,000 or less $180,001 $210,000 $210,001 -$280,000 $280,001 or more Under 65 Between 65 and and over For more information on which level is appropriate please read the Important Information Guide or contact GMHBA on Your full name as it appears on your Medicare card: Your Medicare card Number: Valid to: / / Your current postal address: Your residential address: Your day time phone number: Work: Home: Your date of birth: / / Sex: Are all the people on the policy listed on a Medicare card or entitled to a Medicare card? Yes No Details of all people covered by the policy: Name Date of Birth Relationship/Dependant Child Gender A child is a dependant if: - the child is under the age of 21 years or a full-time student under 25 years. - the child is covered by your insurance policy and GMHBA Health Insurance accepts the child as a dependant child on the policy. - the child is not a partner of another person. You are entitled to a Medicare card if: - you are a person who lives 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. Any inquiries about Medicare eligibility can be made at any Department of Human Services service centre or by phoning Declaration: I declare that the information I have provided is correct. I understand that there are penalties for giving false or misleading information. Signed Date / / Please send this registration form to GMHBA Health Insurance at the address below. Privacy Note Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. Your information may be used by the department or given to other parties for the purposes of research, investigation or where you have agreed or it is required or authorised by law. You can get more information about the way in which the Department of Human Services will manage your personal information, including our privacy policy at or by requesting a copy from the department.

5 Direct Debit Request Member Number: Member Name: Street Address: Suburb: State: Postcode: I/We authorise and request User ID No to arrange for funds to be debited from my/our account at the financial institution identified below and as prescribed below through the Bulk Electronic Clearing System (BECS) and to apply these funds in payment of the member s premium up to the next direct debit date, including any arrears of premium. This authorisation is to remain in force in accordance with the terms described in the Direct Debit Request Service Agreement (see over). Bank/Financial Institution: Bank Name: Bank Address: Account Name: BSB Number: Account Number: The frequency of the direct debit is (fortnightly, monthly, quarterly, half yearly, yearly) The first direct debit is to take place on / / (excluding the 29th, 30th & 31st of any month) I/We have read and accept the terms of the Direct Debit Request Service Agreement as may be amended from time to time by GMHBA and authorise the following: 1. GMHBA to verify the details of the above mentioned account with my/our financial institution 2. My/Our financial institution to release information allowing GMHBA to verify the above mentioned account details. Signature of account holder/s: Date: / / Please note that the above signature must have legal responsibility for the membership.

6 Transfer Certificate Request Please complete this form if you want GMHBA to terminate your membership with another health fund and request a transfer certificate and claims history on your behalf. This form must be signed by the member who has legal responsibility for membership of your previous fund. Health Fund: Member Number: Member Name: Full names and dates of birth of all people who you wish to cancel and transfer to GMHBA: address: Street address: Suburb/city: State: Postcode: I authorise GMHBA to cancel my Hospital only Extras only Combined cover with your fund from: Date / / Signed Date / / Please find my premiums paid in advance of the cancellation date and send a transfer certificate and claims history for all people covered under my membership to GMHBA. Remember, continuity of a member s/partner s certified age at entry (CAE) is possible when transferring from another Australian registered health fund under Lifetime Health Cover. Please do not contact me further about this request.

7 Credit card authorisation Member name Date / / Member number Phone address Address Suburb/city State Postcode I hereby authorise to charge my credit card A on this occasion for the amount of $ B automatically, each Month Quarter Half year Year Until instructed by me in writing to cease deductions. I understand that the first credit charge will occur on / / (first working day of the month) I also authorise to charge my credit card such amount as is required to pay the member s premium up to the next charge date. If the premium changes or payments are in arrears, I authorise to alter the amount from the appropriate date in accordance with such changes. Alterations/cancellations to membership or account details must be received in writing on the prescribed form/s at least seven days before the next scheduled direct debit deduction date. A refund of premiums cannot be issued within 14 days of the debit date. This allows sufficient time for the financial institution to advise GMHBA of any debit deduction dishonour. After two consecutive dishonours, GMHBA will remove the membership from the debit scheme. Type of credit card Mastercard Visa Card Card number Expiry date / / Cardholder s name (If different from member name) Cardholder s signature

8 Application checklist Application form Application to receive the Australian Government Rebate on private health insurance as a reduced premium form Direct Debit or Credit Card Authorisation form Transfer Certificate Request Form (if transferring from another health fund) Once we have processed your membership we will: - Send your welcome pack and membership card. - Start your direct debits (if applicable). - For transferring members, send your Transfer Certificate Request to your previous health fund. Please send your transfer certificate and claims history to us as soon as you receive it from your previous health fund. Any premiums paid in advance will be refunded. What promoted you to consider GMHBA? Please keep the Important Information Guide with your other GMHBA documents.