Mater Maternity Care contact details:

Rocklands Road
North Sydney NSW 2060
Telephone: (02) 9900 7690
Facsimile: (02) 9900 7680
Mater.MaternityBookings @svha.org.au
www.materhospital.com.au

MATER MATERNITY BOOKING FORM

Please complete the following additional Health Fund details
and return form to Mater Maternity Bookings together with the:
● Registration & Pre-admission details &
● Privacy Collection Statement forms

Additional Health Fund information

Surname: Given name: Date of birth
Patient
details

Contributor’s
Name

Level of cover Single Family Overseas Cover No Cover Couples

NB: ● Single Membership DOES NOT COVER charges you will incur if your baby requires treatment
to the Neonatal Intensive Care Nursery. Please discuss with Maternity Bookings

● Self insured patients and patients with overseas cover are required to pay the estimated cost
of hospitalisation two months PRIOR to confinement

I certify that the information shown on my Mater Booking Form and Health Fund information on the
Registration & Pre-admission details are true & I agree to any medical information being given to my
Health Fund in support of my claim. In consideration of the Mater Hospital Sydney agreeing to admit
me as a patient to the Hospital

I, .................................................................................................................
Name of Patient / Guardian (delete as required)

Hereby acknowledge to the St Vincent’s Private Hospitals Limited that I am personally liable for the
payment of all fees and charges of whatsoever nature and kind incurred by me or on my behalf during
Patient my stay at the Mater Hospital Sydney, including but without limiting the generality there of the Delivery
Suite fee, the daily bed fee, the theatre fee and the theatre extras, telephone/fascimile, charges for
Declaration
medications and physiotherapy or other specific treatments and I agree that I shall forthwith pay all such
fees and charges to St Vincent’s Private Hospitals Limited upon demand whether orally or in writing being
made therefore by St Vincent’s Private Hospitals LImited. I further agree that I shall be liable for all costs,
expenses, legal and otherwise incurred by St Vincent’s Private Hospitals Limited in seeking to obtain
payment of such fees and charges or in any way in connection therewith

..................................................................................................................................
Signature of Patient / Guardian (delete as required)
2 0
..................................................................................................................................
Admitting Officer Signature Date

Visa Mastercard Amex Cardholder’s Name: .........................................................................................

/ .......................................................
Booking Card Number Expiry date Amount Cardholder’s Signature
Deposit details
Cash Cheque Credit Card ........................................... Date: 2 0

Receipt Number ..................................... Received by: ..........................................................................................

Revised Mater Hospital Sydney form_V2_March17_for Mater Maternity Bookings only (Re-order no. 018437)