Authority form
WHAT IS AN AUTHORISED PERSON?
Members may wish to have someone else act on their behalf
when dealing with Medibank. Where you nominate someone else
to deal with us on your behalf, they are listed on your membership
as an ‘Authorised Person’.
WHAT IS AN AUTHORISED PERSON ABLE TO DO?
When you nominate an Authorised Person, you can give them the ability to:
1. Conduct all business on your membership
This enables them to make any changes you can make to the
membership yourself, including changing payment details,
adding or removing members or closing the membership.
OR
2. Conduct specific business only
This limits their authority to what you specify. This can be useful if you
only want the person to do something specific on your membership.
At the time of nominating an Authorised Person, you also need to
tell us how long you would like their authority to last. It can be either
ongoing or for a specified period of time.
HOW TO NOMINATE AN AUTHORISED PERSON
You can nominate an Authorised Person by:
1. Calling us on 132 331
2. Completing and returning this form to us:
a. at a Medibank retail store
b. by email: Ask_Us@medibank.com.au
c. by post: Medibank GPO Box 9999 in your capital city, or
3.Providing us with a valid Power of Attorney that gives the person
authority to act on your behalf.
IMPORTANT THINGS TO KNOW WHEN NOMINATING
AN AUTHORISED PERSON
1. You can manage or remove their authority at any time by calling
us on 132 331 or visiting one of our stores.
2.We will do an ID check whenever the Authorised Person contacts us.
If you would like to, you can also provide a security PIN that they will
need to provide when they contact us.
3.Before nominating the Authorised Person you must have obtained
their permission to provide us with their personal information. You
must tell the Authorised Person that you have nominated them, what
information you have given us and that they can obtain a copy of our
Privacy Policy by visiting our website at www.medibank.com.au.
MEDIBANK’S PRIVACY STATEMENT
We collect and use personal information from this form to enable
another person to deal with us on your behalf. If we do not collect this
information, we may not be able to provide you with this service.
We may disclose personal information to persons or organisations in
Australia or overseas including other Medibank Group Companies and
our service providers, professional advisers, suppliers and partners.
We may also disclose information to other persons covered under
your policy or your agents and advisers. We may disclose personal
information overseas to other Medibank Group Companies or third
parties who provide services to us, including in India, the United States
and New Zealand.
Our Privacy Policy contains more information about our privacy
practices, including how you may request access to, or correction of,
personal information, how to lodge a privacy complaint and how we
manage such complaints. You can obtain a copy of our Privacy Policy
by visiting our website at www.medibank.com.au.
Again, you must ensure that you let your nominated Authorised Person
know what information you are giving us and that you have their
consent to do so. You must also let them know how to obtain a copy
of Medibank’s Privacy Policy.
Member to complete
Title
Authorise and request that Medibank grant:
Title
First name
Family name
Address
Suburb/City
State
Postcode
Date of birth (DD/MM/YYYY)
Medibank membership number (if you have one)
the right to:
either
Conduct all business with Medibank
that I am entitled to conduct, on my behalf
or
Conduct the specific business of:
the duration of the granting of this right is:
either
Enduring (for the lifetime of my membership or
when terminated upon request from me)
or
Fixed by the periods:
Start date
Expiry date
Declaration
I may terminate the granting of this right at any time. I acknowledge and
agree with Medibank’s Privacy Policy and will communicate information
contained in the Policy to the Authorised Person nominated on this form.
I declare that the information I have provided is correct. I understand
that there are penalties for giving false or misleading information.
Signature
Date
OPTIONAL: YOU CAN NOMINATE A SECURITY PIN THAT THE AUTHORISED
PERSON WILL NEED TO PROVIDE WHEN THEY CONTACT US.
PIN No: (must be six digits not starting with 0)
Please also choose a challenge question and write the answer in
the space provided:
What is the name of your first pet?
What was the first record or CD you bought?
Where were you born?
What is your grandfather’s name?
Answer:
First name
Family name
Address
Suburb/City
State
Postcode
Date of birth (DD/MM/YYYY)
Medibank membership number (if you have one)
Medibank Private Limited ABN 47 080 890 259. MPL31831214
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