Application to receive the Australian Government Rebate on

Private Health Insurance as a reduced premium

Complete this registration form and lodge it with ahm health insurance to apply to receive the Australian Government Rebate as a reduced premium.
This application must be completed in black pen using block letters.
All the people listed on the policy must be eligible to claim Medicare for you to receive the rebate as a reduced premium.
If at any stage you wish to nominate a new income tier or stop receiving the Australian Government Rebate as a reduced premium, you must notify ahm Health
Insurance as soon as possible.
Name of private health fund issuing the policy to which this application relates: ahm health insurance
Membership number Are you covered by this policy? Yes No
(If no) Applicants not covered by the policy cannot claim the Australian Government Rebate on Private Health Inurance (excluding child only policies) and
employers and trustees of organisations cannot claim the Australian Government Rebate on Private Health Insurance on policies paid on behalf of employees.
Date premium reduction to commence/policy commencement
Nominate a rebate percentage
The rebate percentage youre entitled to depends on your or your familys income. * See the table below for a guide. If you'd like to nominate a rebate
percentage, simply tick the box which applies to you. If you don't nominate a percentage, we'll apply a base tier percentage based on your age.

Base Tier Tier 1 Tier 2 Tier 3

Income* thresholds from 1 April 2016 to 30 June 2018
Singles Up to $90,000 $90,001 $105,000 $105,001 $140,000 $140,001 and above
Couples/families Up to $180,000 $180,001 $210,000 $210,001 $280,000 $280,001 and above
2016 rebate entitlement based on age and income (changes anually on 1 April)

Less than 65 years 26.791% 17.861% 8.930% 0.000%

65 69 years 31.256% 22.326% 13.395% 0.000%
70 years + 35.722% 26.791% 17.861% 0.000%
* This is your income for Medicare Levy Surcharge purposes, which is different to taxable income. For more information please consult your tax adviser or contact the Australian Taxation
Office. The family income threshold is increased by $1,500 for each dependent child after the first. Single Parent families are subject to the family income tiers.

Your Medicare card details

Medicare card number Medicare card valid to

Your full name as it appears on your Medicare card

Permanent/Residential address

Suburb/City State Postcode

Postal address (if different to above)

Suburb/City State Postcode

Your daytime phone number (should we need to contact you)
Work Home Mobile

Date of birth Sex/Gender Male Female

Details of all people covered by the policy (do not include yourself)
Family name Given name(s) Date of birth Sex/Gender Relationship to applicant
Dependent child
M F Y N

M F Y N

M F Y N

M F Y N

M F Y N

M F Y N

Are all the people on the policy listed on a Medicare card or entitled to a Medicare card? Yes No
For a definition of dependent child and for details on Medicare card entitlement, please refer over the page.
Declaration Privacy notice - Your personal information is protected by law, including the Privacy Act 1988, and is collected
by the Australian Government Department of Human Services for the assessment and administration of
I declare that the information I have provided is correct. I understand
payments and services. This information is required to process your application or claim.
that there are penalties for giving false or misleading information.
Your information may be used by the department or given to other parties for purposes of research,
investiagion or where you have agreed or it is required or authosied by law.
Signature
You can get more information about the way in which the Department of Human Services will manage your
personal information, including our privacy policy at www.humanservices.gov.au/privacy or by requesting a
copy from the department.
Date

Sign and email this form to info@ahm.com.au or post to ahm health insurance, Locked Bag 4, Wetherill Park NSW 2164
Dependent child
A child is dependent if the child is under the age of 25 and is covered by your ahm Insurance policy as a Dependant.

Medicare card entitlement

You may be entitled to a Medicare card if you are:
a person who lives in Australia;
an Australian citizen;
a holder of a permanent resident visa;
a New Zealand citizen or, in some cases, an applicant for a permanent resident visa.
For more information about the Australian Government Rebate on Private Health Insurance, go to humanservices.gov.au/
privatehealth
Questions about Medicare eligibility can be made at any Human Service Centre or by calling 132 011.
or go to:
https://www.humanservices.gov.au/customer/services/medicare/medicare-card
Note: Call charges apply - calls from mobile phones may be charged at a higher rate.