7/29/2019 Australian Government Rebate Application Form

1/2

Application to receive the Australian Government Rebateon private health insurance as a reduced premium

Medibank Private Limited ABN 47 080 890 259MPL31820512

CompletethisregistrationformandlodgeitwithMedibanktoapplytoreceivetheAustralianGovernmentRebateasareducedpremium.

Thisapplicationmustbecompletedinblackpenusingblockletters.

AllthepeoplelistedonthepolicymustbeeligibletoclaimMedicareforyoutoreceivetherebateasareducedpremium.

IfatanystageyouwishtostopreceivingtheAustralianGovernmentRebateasareducedpremium,youmustnotifyMedibankassoonaspossible.

Name of private health fund issuing the policy to which this application relates: Medibank

Membership number Are you covered by this policy? Yes No

(If no) employers and trustees of organisations cannot claim the Australian Government Rebate on policies paid on behalf of employees.

Date your premium reduction to commence

Nominate a rebate percentageThe rebate percentage youre entitled to depends on your or your familys income* refer to the table below for a guide.If youd like to nominate a rebate percentage, simply tick the box which applies to you. If you dont nominate a percentage, well apply a base tierpercentage based on your age.

BaseTier Tier1 Tier2 Tier3

Income*thresholdsfor2012-2013financialyear

Singles Up to $84,000 $84,001 $97,000 $97,001 $130,000 $130,001 and above

Couples/families Up to $168,000 $168,001 $194,000 $194,001 $260,000 $260,001 and above

Rebateentitlementbasedonageandincome

Less than 65 years 30% 20% 10% 0%

65 69 years 35% 25% 15% 0%

70 years + 40% 30% 20% 0%

*This is your income for Medicare Levy Surcharge purposes, which is different to taxable income. For more information please consult your tax adviser or contact the Australian Taxation Office.

YourMedicarecarddetails

Number Valid to

Your full name as it appears on your Medicare card

Your current postal address

Suburb/City State Postcode

Your residential address

Suburb/City State Postcode

Your daytime phone number (should we need to contact you)

Work Home Mobile

Date of birth Sex Male Female

Details of all people covered by the policy (do not include yourself)

Familyname Givenname(s) Dateofbirth Sex Dependentchild

M F Y N

M F Y N

M F Y N

M F Y N

M F Y N

M F Y N

AreallthepeopleonthepolicylistedonaMedicarecardorentitledtoaMedicarecard? Yes No

For a definition of dependent child and for detail s on Medicare card entitlement, please refer over the page.

Print form Reset form

Declaration

I declare that the information I have provided is correct. I understand

that there are penalties for giving false or misleading information.

Signature

Date

continued over

The information provided on this form will be used for the purpose of registering

you for the Australian Government Rebate. Its collection is authorised by lawand information collected may be disclosed to the Department of Health andAgeing, the Department of Human Services and the Australian Taxation Office.

SendformtoMedibankbyposttoMedibank,GPOBox9999inyourcapitalcityorbyfaxto(07)30260557.

7/29/2019 Australian Government Rebate Application Form

2/2Medibank Private Limited ABN 47 080 890 259MPL31800612

You can return this form viafax to (07)30260557 or postit to Medibank, GPO Box 9999

in your capital city.

If youd like to completethis form online, log in to

Online Member Services atmedibank.com.au

Dependentchild

A child is dependent if:

thechildisundertheageof18years,orafull-timestudentundertheageof25;

thechildiscoveredbyyourinsurancepolicyandyourhealthfundacceptsthechildasadependentchildonthepolicy;

thechildisnotthepartnerofanotherperson.

Medicarecardentitlement

You are entitled to a Medicare card if you are:

apersonwholivesinAustralia; anAustraliancitizen;

aholderofapermanentresidentvisa;

aNewZealandcitizenor,insomecases,anapplicantforapermanentresidentvisa.

Any enquiries about Medicare eligibility can be made at any Department of Human Services ser vice centre or by phoning 132 011for the cost of a local call.