Please complete all details (where applicable) and attach full itemised accounts/receipts.
You may email the completed form with receipts to Navy Health will retain all original accounts and receipts.
Member Surname Member No
Change of Contact Details or Direct Credit details included (overleaf)
Claim Details
Patient First Name Patient DOB Provider No Service Date Fee Paid Service Type
Are the charges in this claim recoverable as damages, compensation or benefit under any Repatriation, Worker’s Compensation TAC, Social Services or other Acts, Rules and
Regulations or from any other third party?
No Yes (Provide Details)
I declare that the information on this form is true and correct. I authorise Navy Health to check any of these services with the relevant providers authorise Navy
Health to contact the provider to obtain any necessary information to either verify or audit this claim. I declare these services cannot be claimed from any other
source unless specified in the compensation section of this form.
Member Signature Date
Claim Form
Please use black pen and print upper case.
Avoid contact with the edge of the box.
Please enter all details of claim that are shown on invoice/receipt.
JOHN DDMMYY 0112632B DDMMYY 9999.99 Dentist
Change of Address (Only complete if your details have changed)
Street Address
Suburb State Postcode
Contact Phone Mobile Phone
Direct Credit Details (Only complete if your details have changed) Update direct credit details for future transactions? Yes No
Account Name BSB Number Account Number
Important Information
fit year(s)
Extras annual limits and service are based on financial years (1 July to 30 June). The date of service determines from which year the benefit is drawn. Hospital excesses are
payable once per person (up to twice per membership) in a rolling 12 month period, from the first date of admission.
Benefits are not payable where the service date is during a period of suspension, whilst the membership is unfinancial, or if the claim is submitted more than two years after the
date of service. Receipts will remain the property of Navy Health Ltd. Please make photocopies prior to submitting claims if you require them for your records.
Medical Prescribed Appliances (MPAs)
Receipts must be accompanied by a referral from a physiotherapist, chiropractor, osteopath or medical practitioner. The referral must state the patient name and that the
purchase is for medical reasons.
Did You Know?
You can update your details, view your claims history and more, via logging onto Online Member Services at and registering for access.
When claiming your benefits, at most providers, you can simply swipe your membership card at the time of service and have the claim immediately processed - no need to fill
out any forms.
Navy Health Limited
A Registered Private Health Insurer
ABN 61 092 229 000
PO Box 172, Box Hill VIC 3128
Telephone 1300 306 289 Fax 03 9880 7939
Email Web