Young Adult Membership Application Form

Size: px

Start display at page:

Download "Young Adult Membership Application Form"

Edwin Powell
5 years ago
Views:

1 Young Adult Membership Application Form Return completed form to: Navy Health PO Box 172 Box Hill VIC 3128 or to For more information, please call

2 Current member to complete: (eg. parent, power of attorney) 1. Young Adult Membership eligibility Member name Membership number (if known) I acknowledge that is no longer entitled to full dependant cover under my membership. They have chosen to take out: Extras cover on their own policy and retain hospital cover under my membership as part of Navy Health s Young Adult membership. Independent cover, as they do not qualify for Young Adult Membership. To apply, please go to navyhealth.com.au or for more information phone I have enclosed all completed application forms. I acknowledge that Young Adult Membership hospital cover is subject to any movement of cover on my membership and my dependant maintaining eligibility under the scheme. I will inform Navy Health of any change in circumstance that will affect my dependant s eligibility. Parent s Signature Young adult to complete: 1. What are your details? Title Family name Given names First Address Suburb State Postcode Phone (Business hours) Phone (After hours) Mobile Gender M/F of Birth Please tick box if you wish to receive membership information via SMS

3 2. Would you like to allow others to operate your membership? (Young adult to complete) Do you authorise another person to operate this membership? (e.g. parent, power of attorney*) Yes No Name Relationship To operate membership OR To query membership * Requires Power of Attorney documentation to be provided. 3. What level of extras cover do you require? (Young adult to complete) Premium Extras Healthy Living Extras Basic Extras to commence from 4. Payment Options (Young adult to complete) Monthly Half-yearly Yearly For the amount of $. Direct debit Bank/Financial institution I/we request Navy Health (Id. No ) to debit funds from my/our nominated account according to the details specified below through the Electronic Banking System. This authorisation is to remain in force in accordance with the terms described in the Direct Debit Service Agreement. If my premium for my cover changes, I authorise Navy Health to alter the amount to be charged, from the appropriate date, and for the appropriate amount. Financial institution Account name BSB number Account number I/we request that you debit the amount listed above, at the payment frequency specified. The exact debit amount will under normal circumstances reflect your regular premium however debits may vary if payment amounts are not received within stated guidelines. I/we authorise the following: 1. The direct debit user to verify the details of the above mentioned account with my/our financial institution. 2. The financial institution to release information allowing the debit user to verify the above mentioned account details. Signature Direct debit Credit card To protect your privacy Navy Health cannot request credit card information to be written on the application form. If you would prefer to pay your premiums with a credit card, please tick the box above and we will contact you regarding your ongoing credit card payment once your membership application is completed.

4 5. Declaration I have read and understood the information and conditions associated with my policy and accept to abide by the rules of the fund. I acknowledge that I have read, understood and retained the information provided to me regarding pre-existing conditions, waiting periods, benefit limitations, and excesses that may apply. Signature canijoin.com.au navyhealth.com.au Navy Health Limited A Registered Private Health Insurer ABN PO Box 172, Box Hill, Victoria query@navyhealth.com.au

5 Application to receive the Australian Government rebate on private health insurance as a reduced premium Membership number (if known) Title/Rank Family name Given names First Address Suburb State Postcode Postal address ( if different to above) Address Suburb State Postcode Phone (Business hours) Phone (After hours) Mobile Gender M/F of birth Your Valid to / Are you covered by the policy? Yes No Your name and subnumerate digit exactly as it appears on your Medicare card Dependants on your policy: 1. Title/Rank Family name Relationship to applicant Gender M/F of birth 2. Title/Rank Family name Relationship to applicant Gender M/F of birth 3. Title/Rank Family name Relationship to applicant Gender M/F of birth 4. Title/Rank Family name Relationship to applicant Gender M/F of birth

6 You may be entitled to a Medicare card if you are: a person who lives in Australia, and an Australian citizen, or a holder of a permanent resident visa, or a New Zealand citizen, or an applicant for a permanent resident visa. For more information about the Australian Government Rebate on Private Health Insurance, go to humanservices.gov.au/privatehealth. Questions about Medicare eligibility can be made at any Human Services Service Centre or by calling or go to medicare/medicare-card Note: Call charges apply - calls from mobile phones may be charged at a higher rate. Are you covered by the policy? 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. Are all the persons on the Navy Health Policy listed on the Medicare card or entitled to a Medicare card? Yes No Please complete this section if you wish to receive the Australian Government rebate on Private Health Insurance (PHI) as a reduced premium on your health cover. The PHI rebate is income tested against the income tier thresholds as defined by the Australian Tax Office (for more information refer to navyhealth.com.au or ato.gov.au). Your rebate entitlement may be reduced as your income tier rises. Please review the income tier thresholds online before selecting the rebate (tier) you believe you are entitled to below. 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 Navy Health as soon as possible. Base Tier Tier 1 Tier 2 Tier 3 premium reduction to commence All people listed on the policy must be eligible to claim Medicare for you to receive the rebate as a reduced premium. Declaration I declare that the information provided is correct. I understand that there are penalties for giving false or misleading information. (If this is a military membership then the Medicare cardholder must sign this form). Claimant Signature Privacy Notice: The information provided by you on this form will be used for the purpose of registering you for the Australian 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, Department of Human Services, and the Australian Taxation Office. You can get more information about the way in which Navy Health will manage your personal information, including our privacy policy at navyhealth.com.au/privacy or by requesting a copy from Navy Health. Return completed form to: Navy Health PO Box 172 Box Hill VIC 3128 or to query@navyhealth.com.au For more information, please call

Your application. X Join X. X Male X Female. X X Mail. SECTION A: I m applying to. SECTION B: Your details. SECTION C: Contact details

Your application. X Join X. X Male X Female. X X Mail. SECTION A: I m applying to. SECTION B: Your details. SECTION C: Contact details Your application 1. Please complete this form USING BLACK INK and write within the boxes in CAPITAL LTTRS. Mark appropriate answer boxes with a CROSS. Start at the left of each answer space and leave a