Member Application
membership no.
Your details
title
surname
given names
home address
suburb
postcode
postal address
suburb
postcode
sex
birth date
/
/
home telephone (
)
work telephone (
mobile
)
email
Your Medicare card number
/
valid to
Medicare ref no.
Your partner and/or additional family member details If you need to add more than 5 people, please attach a separate page with their details.
My eligible dependants (refer to rule 9 on page 28, membership conditions in this brochure) including partner/spouse. Student dependants must be registered with the Fund each year.
surname
given names
Are you and your dependant/s Australian Residents? relationship
birthdate
Medicare ref no. sex
/
/
/
/
/
/
/
/
/
/
No
Yes
Partner authority
If you wish to authorise your partner, as named above, to also operate this membership please tick this box.
Transfer details
If transferring to St.LukesHealth from another health fund. You will also need to complete the ‘Clearance certificate request’ below
Your cover requirement
new
change
/
date cover / change to commence
Your Choice Hospital cover /
Your Choice Extras cover Your Choice Packaged cover Cover type
Hospital Platinum (Nil excess)
Extras Platinum
Packaged Platinum Plus
Single
Hospital 100
Hospital 400
Extras Basic
Packaged 300
Family/Couple
Hospital 200
Hospital 500
Packaged 500
Hospital 300
Hospital 1000
Packaged Basic
Pre-existing ailment
A 12 month waiting period applies to pre-existing ailments. A pre-existing ailment is an ailment, illness or condition the signs or symptoms of which existed at any time in the
period of 6 months ending on the day on which the member became insured under the policy. Other waiting periods may apply. For more information on waiting periods refer
to membership conditions 1 and 2 on page 27.
If you are transferring your cover some waiting periods may not apply. Refer to membership conditions 10 and 11 on page 28.
I have read and understood the information regarding the pre-existing waiting period
Please initial
Federal Government Rebate
Do you wish to receive the rebate as a reduced premium?
Yes
No
Are all people on your membership eligible for a current Medicare card?
Yes
No
If YES, please complete the remainder of this section. If NO, you cannot apply for the rebate until you obtain a card from Medicare.
Are you covered by this membership?
No
Yes
If at any stage you wish to stop receiving the Federal Government Rebate as a reduced premium, you must notify St.LukesHealth in writing as soon as possible.
Some of the information provided on this form will be used for the purpose of registering you for the Federal Government Rebate on private health insurance.
Its collection is authorised by law, and information collected will be disclosed to the Department of Health and Ageing, Medicare Australia and Australian Taxation Office.
Payment method
weekly
fortnightly payroll deduction
monthly quarterly yearly
half yearly name of employer
bank, building society, credit union or credit card (Please complete direct debit request on the back of this form).
direct debit
Please turn over
Authority to deduct from salary
title
surname
given names
home address
suburb
membership number
postcode
payroll no.
dept no.
I authorise the pay officer for:
company name
To deduct from my salary $
every /
commencing pay period ending
first authority
week fortnight month
/
change to existing authority
old deduction $
new deduction $
I authorise the pay officer to cancel my existing health insurance deductions from:
fund name
from the above pay period.
Should the amount of contribution payable by me be altered by reason of an alteration in the rate of contribution for the product under which I am covered, then this authority
and request shall extend to and covers the altered contribution payable by me.I authorise you to accept from time to time notification from the fund that my contribution to
the product under which I am covered has been varied to an amount specified and request that this should be acted upon. This authority is to continue until such time as it is
withdrawn by me in writing.
signature
date
office use only
/
/
group number
section number
Clearance certificate request
If you are transferring from another Health Fund, complete this form to authorise St.LukesHealth to cancel your existing membership.
Details of previous health fund
name of previous fund
previous fund membership no.
name of previous fund
previous fund membership no.
Details of individuals covered by previous health fund If you need to add more than 4 people, please attach a separate page with their details.
full name of policy holder
birth date
/
/
dependants name
birth date
/
/
dependants name
birth date
/
/
dependants name
birth date
/
/
dependants name
birth date
/
/
Authority to cancel
I hereby authorise St.LukesHealth to cancel my membership from
/
/
and obtain all relevant information about my membership.
I also request a refund for any premiums paid in advance of my cancellation date.
Please note if your premiums to your previous fund are made by wage/payroll deductions or by Direct Debit you should advise your paymaster or financial institution to cease
deductions accordingly.
signature
Please return completed form to:
office use only
date
/
St.LukesHealth
PO Box 915
Launceston Tas 7250
Ph: 1300 651 988
Fax: (03) 6331 9095
St.LukesHealth membership no.
/
signature
date
/
/