Rebate Application Form

Australian Government Rebate on Private Health Insurance

• Complete this registration form and lodge it with Australian Unity to confirm if you can receive the Australian Government Rebate on Private Health
Insurance as a reduced membership premium. The form must be returned to Australian Unity within 10 days so that Australian Unity is able to apply the
rebate to your premiums from the start of your membership.
• All the people listed on the membership must be eligible to claim Medicare for you to receive the rebate as a reduced premium.
• If at any stage you wish to stop receiving the Australian Government Rebate on Private Health Insurance as a reduced premium, you must notify
Australian Unity as soon as possible.

Name of private health fund issuing the policy to which this application relates: AUSTRALIAN UNITY

1 Your Membership Details Review

Your Membership Number Cover Name

Date premium reduction to commence

D D / M M / Y Y
Yes No
Are you covered by this policy?
 ou may register for this scheme if the cover is only for your dependent child and you are the parent of that child.
Y
(If no) Employers and trustees of organisations cannot claim the Australian Government Rebate on Private Health Insurance on policies paid on behalf of employees.

2 Your Medicare Card Details Complete

Your Medicare card number Valid to
M M / Y Y Y Y

Your full name as it appears on your Medicare card

3 Your Personal Details Complete

Your current postal address Suburb State Postcode

Your residential address (If same as above please write “as above”)

Suburb State Postcode

Your daytime phone number (should we need to contact you) Date of birth Male Female
D D / M M / Y Y

4 Your income for Australian Government Rebate purposes Complete

Please select your Rebate tier in the table below.

Income tiers Tier breakdown

Income

No Tier Tier 1 Tier 2 Tier 3

Singles $90,000 or less $90,001 – $105,000 $105,001 – $140,000 Over $140,001

Couples/Families $180,000 or less $180,001 – $210,000 $210,001 – $280,000 Over $280,001

The table above shows rebate entitlement based on your income for Medicare Levy Surcharge purposes. For families with children, the thresholds are
increased by $1,500 for each child after the first. These thresholds increase annually on 1 July, based on growth in Average Weekly Ordinary Time Earnings.
Health insurers are not permitted to provide tax advice. For assistance in determining your appropriate tier please contact your registered tax agent or
the Australian Tax Office at ato.gov.au

(Please turn over)

Rebate Application Form

5 Details of all people covered by the policy (do not include yourself) Complete

Date of Birth Dependent

Family Name Given Name(s) (dd/mm/yyyy) Sex 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

A child is a dependant if:

• the child is under the age of 23 years, or a full-time student under the age of 25;
• the child is covered by your insurance cover and Australian Unity accepts the child as a dependant child on the cover;
• the child is not a partner of another person.

6 Are all the people on the cover listed on a Medicare card or entitled to a Medicare card? Complete

Yes No

You are 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.
Any enquiries about Medicare eligibility can be made at any Medicare office or by phoning 13 20 11 for the cost of a local call.

7 Declaration Sign
I declare that the information I have provided is correct. I understand that there are penalties for giving false or misleading information.

Signature Date
SIGN D D M M Y Y
HERE / /

Privacy Note: The information provided on this form will be used for the purposes of registering you for the Australian Government Rebate on Private Health Insurance.
Its collection is authorised by law, and information collected may be disclosed to the Department of Health and Ageing, the Department of Human Services, and the
Australian Taxation Office.

8 Returning your documents Return

Please return your completed and signed form to Australian Unity within 10 days by:
Mail: Australian Unity, Health Membership Email: customerservice@australianunity.com.au Fax: 1800 852 030
Reply Paid 64466, Melbourne VIC 8060
(No stamp is required)

For further information visit australianunity.com.au or call us on 13 29 39

Australian Unity Health Limited ABN 13 078 722 568 114 Albert Road, South Melbourne Victoria 3205
517AUH_0415