Membership number (if known)
Your full name exactly as it appears on your Medicare card
Title/Rank
Family name
First name
Address
Suburb
State
Postcode
Postal address ( if dierent to above)
Address
Suburb
State
Postcode
Daytime phone
Gender: Male
Female
Date of birth
Your Medicare card number
Valid to
Are you covered by the policy? Yes No
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
All people listed on the policy must be eligible to claim Medicare for you to receive the rebate as a reduced premium. If you are unsure whether you are
eligible for Medicare, go to www.humanservices.gov.au/customer/services/medicare/medicare-card for more information.
Family name First name
Dependant child: Yes No Gender: Male
Female
Date of birth
Family name First name
Dependant child: Yes No Gender: Male
Female
Date of birth
Family name First name
Dependant child: Yes No Gender: Male
Female
Date of birth
Family name First name
Dependant child: Yes No Gender: Male
Female
Date of birth
Family name First name
Dependant child: Yes No Gender: Male
Female
Date of birth
If there are more people covered by the policy, attach a separate sheet with details.
Application to receive the Australian
Government Rebate on Private Health
Insurance as a reduced premium
A
pplicant details (must be an adult covered by the policy)
Are you covered by the policy?
Provide details of all people covered by the policy
(do not include yourself)
A permanent ADF member is NOT to be the applicant, unless the policy covers children only.
The PHI rebate is income tested against the income tier thresholds as defined by the Australian Tax Oce (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
Date premium reduction to commence (dd/mm/yy)
I declare that:
• the information I have provided in this form is complete and correct.
I understand that:
• giving false or misleading information is a serious oence.
(If this is a military membership then the Medicare cardholder must sign this form).
Applicant Signature
Date (dd/mm/yy)
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 Oce. 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 email to query@navyhealth.com.au
For more information, please call 1300 306 289.
Income Tier
Commence date
Declaration
For more information about the Australian Government Rebate on Private Health Insurance,
go to privatehealth.gov.au
Questions about Medicare eligibility can be made at any Human Services’ Service Centre or
by calling 132 011.
Note: Call charges apply - calls from mobile phones may be charged at a higher rate.
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome