The PHI rebate is income tested against the income tier thresholds as deﬁned by the Australian Tax Oce (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.
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 oence.
(If this is a military membership then the Medicare cardholder must sign this form).
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 Oce. You can get more information about the
requesting a copy from Navy Health.
Return completed form to:
Navy Health – PO Box 172 Box Hill VIC 3128
or email to firstname.lastname@example.org
For more information, please call 1300 306 289.
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.
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