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Title:
| Surname:*
| Given Names:*
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Residental Address
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Address:*
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Suburb:*
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Postcode:*
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Postal Address |
As above
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Postal Address:
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Suburb:
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Postcode:
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Phone Home:*
| Is your home phone a silent number?
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Phone Work:
| Date of Birth:*
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Mobile No:
| Email:*
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Enquiry Code (if applicable):
| I do not wish to receive material for the purposes of marketing, promotions or research
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Is this a corporate membership?
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Corporation Name
| Member Number (if applicable)
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Level of Health Cover Required
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Hospital:
| Extras:
| Natural Plus (available with Extras Cover):
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Membership Required
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Family members to be included in your cover
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| Given Names: | Surname: | | Date of Birth: | Gender:
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| | Spouse | | |
| | Child | | |
| | Child | | |
| | Child | | |
| | Child | | |
To be completed by members joining Health Partners
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If you wish to authorise your partner, as named above, to operate this membership, please choose YES.
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Transfer of Membership from another fund
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Previous fund name:
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I wish to resign from my old Fund effective from:
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Membership No.:
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| Please forward to Health Partners a letter of clearance specifying details relating to your membership of your health fund. |
Application for Federal Government 30% Rebate
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Will this policy cover you?
| If No, employers and trustees of organisations cannot claim Federal Government Rebate on policies paid on behalf of employees. |
Your Medicare card Number:
| Valid to:
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Are you a permanent resident of Australia?
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Your name exactly as it appears on your Medicare card
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Are all the people included in this membership entitled to or listed on your Medicare Card?
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Lifetime Health Cover Details |
If you (or your partner, if applicable) are over 30 and have not previously held private health insurance, you will have to pay a loading on your hospital cover. Please click here for further details. |
Have you had continuous private health cover since 1 July 2000?
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If you are transferring from another fund, do you currently have a Lifetime Health Cover loading?
| If yes, please specify
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If you do not provide confirmation that you (or your partner) are exempt from Lifetime Health Cover loading, your (and your partner's) date of birth will be used to calculate the loading that applies to your contribution. |
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Have you spoken to someone at Health Partners?
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If Yes, what was their name?
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How did you hear about Health Partners?*
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Other
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Member Declaration |
I declare the statements in this application are true and complete. I apply for the health cover indicated above and If not already a member, to become a member of Health Partners Limited (ABN 43 128 282 904) and I will be bound by the rules and constitution of Health Partners Limited.
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I agree that I have provided this information with the knowledge that I will now become a member of Health Partners
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| I have read and agree with the important information relating to waiting periods. |
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Thank you for your application for membership.
A confirmation letter of your membership details will be sent to you within 7 working days. |
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| *Required |