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Application for Australian Government Rebate on private health insurance as a reduced membership contributionPlease print in black ink, using capital letters and mark check boxes with an X.Complete this registration form and lodge it with GU Health to apply for the Australian Government Rebate on private health insurance as a reduced membership contribution or to update your rebate tier.• You don’t need to complete this form if you’re currently claiming the Australian Government Rebate on private health insurance as a reduced membership contribution and wish to leave your existing rebate tier unchanged.• All the people listed on the membership must be eligible to claim Medicare entitlements.Please complete the information requested below and send your completed form by:• FreePost to GU Health, Reply Paid 2988, Melbourne Vic 8060 (no stamp required); or• Scan and email to corporate@guhealth.com.auFor assistance or more information call your GU Health Member Relations Team on 1800 249 966 between 8.30am and 5pm (EST) Monday to Fridayor email corporate@guhealth.com.auSection 1: Policyholder’s details (the person in whose name membership is held)Title Surname GenderMFGiven name Date of birthDDMMYYYYHome addressState Postcode Postal addressState Postcode Daytime telephone number GU Health Membership No. (if you have one) Are you covered by this policy? Yes No (If No, employers and trustees of organisations can’t claim the Australian Government Rebate on private health insurance on policies paid on behalf of employees).I wish to (please indicate with an X)Nominate my rebate tier (Must already be claiming Australian Government Rebate on or Apply for the Australian Government Rebate private health insurance as a reduced membership contribution) on private health insurance(Complete Sections: 1, 2, 5) (Complete all Sections)Section 2: Australian Government Rebate on private health insuranceDate membership contribution reduction and/or rebate tier nomination to commence from D DMMYYYYMedicare card number Valid toDDMMYYYYPolicyholder’s name and initial (exactly as they appear on your Medicare card)Please nominate a rebate tier that best reflects your entitlementBase Tier Tier 1 Tier 2 Tier 3If the rebate tier you select doesn’t accurately reflect your actual entitlement as determined by the Australian Taxation Office (ATO), this will be reconciled as part of your tax return.Health insurers are not permitted to provide tax advice. For assistance in determining your appropriate rebate tier, please contact your registered tax agent or the Australian Tax Office at ato.gov.auContinued over pageApplication for Australian Government Rebate Form – GU0014 – AUGUST 2015 INT / WEB
Section 5: Declaration (must be signed)I declare and acknowledge that all the information provided in this form is correct. I understand that there are penalties for giving false or misleading information. Should any of the above details change, I’ll notify GU Health immediately.If at any stage you wish to stop receiving the Australian Government Rebate on private health insurance as a reduced membership contribution or wish to update your rebate tier, you should notify GU Health.Policyholder’s signature Date signedDDMMYYYYThe information provided on this form will be used for the purposes of registering you for the Australian Government Rebate on private health insurance. Collection of this information is authorised by the Private Health Insurance Act 2007.This information may be disclosed to the Department of Health, the Department of Human Services and the Australian Taxation Office or as authorised or required by law.Section 3: About your dependant/sEach person covered on this membership must have Medicare entitlements.SurnameGiven name(s)Date of birth(DD / MM / YYYY)GenderDependant Child//M FYN//MFYN//MFYN//MFYN//MFYN//MFYNSection 4: EligibilityAre all the people on the membership listed on a Medicare card or entitled to a Medicare card? Yes NoIf NO, you can’t apply for the Australian Government Rebate on private health insurance until each person to be covered on the membership has Medicare entitlements.You’re entitled to a Medicare card if• you live in Australia; and• you’re an Australian citizen; or• you hold of a permanent resident visa; or• you’re a New Zealand citizen; or, in some cases an applicant for a permanent-resident visa.If you’re from a country with which Australia has a Reciprocal Health Care Agreement (RHCA), you may be eligible for an RHCA Medicare card.For further details on Medicare eligibility, please contact the Department of Human Services on 132 011 or visit humanservices.gov.au.Application for Australian Government Rebate Form – GU0014 – AUGUST 2015 INT / WEBGrand United Corporate Health Limited (GU Health) ABN 99 002 985 033 is a registered health insurer and a member of the Australian Unity Group. © Grand United Corporate Health Limited 2015. GU Health respects the privacy of our members, view our privacy policy at guhealth.com.au.