Health Benefits Claim Form
Download a blank fillable Health Benefits Claim Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Health Benefits Claim Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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1
2Health benefits claim form
Member details
Accounts/receipts must be attached.
Member number
Title or
First
Last
Rank
name
name
Home
Suburb
State
Postcode
address
Mobile
Email
phone
address
1. Patient(s) detail
Full
Date
Date
Type of
Name of provider
name
of birth
of service
service
(include practice suburb)
Benefits to dependants aged between 21–25 are only payable to full-time students attending school, university or college.
2. Payment to bank account
I authorise Defence Health to:
Account holder name
Pay my benefit into my previously registered account
Pay my benefit for this and all future claims into the account
Name and branch of financial institution
nominated to the right.
It is your responsibility to settle any balance with the provider.
BSB number
Account number
3. Claimable from another source
a. Are any of the services related to an accident, injury or condition which has, or may,
result in compensation or damages from another source (e.g. work, transport accident, etc.)?
Yes
No
If Yes please complete the Accident questionnaire overleaf.
b. Can any of the services be subsidised or claimed from another source
(e.g. DVA, Child Dental Benefits Schedule)? If Yes please provide details.
Yes
No
I declare that:
– I have incurred the expenses in this claim and the information supplied is true and correct.
– I have read the Defence Health Privacy Policy (which I have a copy of or which I can view at .au or request
by calling 1800 335 425). I have informed my dependants about the Privacy Policy. I consent to the use, disclosure and handling
of my personal information and that of my dependants in accordance with that Policy.
– I have obtained the consent of any dependant aged 16 and over to provide the sensitive information required to claim.
– I have informed my dependants who are 16 years and over that they may apply to Defence Health to restrict other policy members
from accessing their personal information.
– I authorise Defence Health to obtain such information as is necessary from the provider to verify or audit this claim.
Signature
Date
/
/
Submit your claim online at .au, via email to claims@.au,
fax to 1800 241 581 or post to Defence Health PO Box 7518 Melbourne VIC 3004
Defence Health Limited ABN 80 008 629 481 AFSL 313890
The Defence Health Privacy Policy can be viewed on our website or call us to have it posted to you.
1261/06-16
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Parent category: Legal