Application To Receive Or Change The Australian Government Rebate On Private Health Insurance As A Reduced Premium
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1
2
3Application to receive or change the
Australian Government Rebate on Private
Health Insurance as a reduced premium
Purpose of this form
Claimant’s details
•
Complete this form and lodge it with your health fund to receive
1
Name of private health fund
the Australian Government Rebate on Private Health Insurance
as a reduced premium.
•
All the people listed on the policy must be eligible to claim
2
Health fund membership number
Medicare for you to receive the rebate as a reduced premium.
•
Policy holders must nominate the income tier they believe they
are entitled to.
3
Are you covered by the policy?
Base Tier
Tier 1
Tier 2
Tier 3
No
Applicants not covered by the policy cannot claim the
Australian Government Rebate on Private Health
Singles
$90 000
$90 001
$105 001
$140 001
Insurance (excluding child only policies) and
or less
to
to
or more
employers and trustees of organisations cannot claim
$105 000
$140 000
the Australian Government Rebate on Private Health
Family/
$180 000
$180 001
$210 001
$280 001
Insurance on policies paid on behalf of employees.
Couples*
or less
to
to
or more
$210 000
$280 000
Yes
Date premium reduction to commence
* Income thresholds increase by $1500 for every child after
/
/
the first.
4
Medicare card number
•
If a policy holder claims an income tier above their actual
entitlement, a recovery of monies will occur through the
Ref no.
Australian Taxation Office (ATO) as a tax debt.
Medicare card valid to:
•
If a policy holder claims an income tier below their actual
/
entitlement, a refund will occur through the ATO as a tax credit.
•
If at any stage you wish to stop receiving or wish to nominate a
5
Family name
new income tier for the Australian Government Rebate on
Private Health Insurance as a reduced premium, you must notify
your health fund as soon as possible.
Given name(s)
For more information
6
Permanent address
For more information about the Australian Government Rebate on
Private Health Insurance, go to our website
humanservices.gov.au/privatehealth
www.
If you need assistance completing this form, visit a Medicare Service
Postcode
Centre or call 132 011.
7
Postal address (if different to above)
Note: Call charges apply – calls from mobile phones may be charged
at a higher rate.
Filling in this form
Postcode
•
Please use black or blue pen
8
Daytime phone number
•
Print in BLOCK LETTERS
(
)
✓
7
•
Mark boxes like this
with a
or
9
Date of birth
Returning your form
/
/
Check that you have answered all the questions you need to answer
10
Sex
and that you have signed and dated this form.
Male
Send the completed and signed form to your nominated health fund.
Female
1 of 3
MS006.1407 (formerly 2838)
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