Health Insurance Application

If you have forgotten to get a quote before opening the application form click here.

All fields marked * are mandatory.

1 - Type of cover
Type of Cover	Single   Couple   Family

2 - your Details
Title*	Title Mr Mrs Ms Dr Miss
Given Names*
Last Name*
Home Address*
Suburb*	State* State ACT NT NSW QLD SA TAS VIC WA   Post Code*
Postal Address (if different)
Suburb	State State ACT NT NSW QLD SA TAS VIC WA   Post Code
Date of Birth*	/ /
Gender*	Male  Female
Phone Contacts*	Home    Day
	Mobile    Fax
Email Address*
Medicare Card Number*	Expiry Date*
Your position number on the Medicare Card*
Your name as appears on the card*
Preferred form of written communication*	Email  Mail

3 - other people to be covered
Note: Children under 21 are covered under family memberships. Children over 21 and under 25 are covered if they are single and undertaking a full-time apprenticeship, full-time traineeship or full-time study at eligible educational institutions (please list below).
Given Name (include Last Name if different to applicant)	Relationship	Date of Birth	Gender	Name of educational Institution
			Gender Male Female
			Gender Male Female
			Gender Male Female
			Gender Male Female
			Gender Male Female
			Gender Male Female
			Gender Male Female
			Gender Male Female
			Gender Male Female
			Gender Male Female

4 - choose your preferred hospital cover
	Cover Type*	Maximum Admission Excess
	I don't need Hospital Cover
	GOLD HOSPITAL Level 0	Nil excess
	GOLD HOSPITAL Level 1	$250
	GOLD HOSPITAL Level 2	$500
	SILVER HOSPITAL Single Parents Hospital	$100
	SILVER HOSPITAL Young Couples Hospital	$100
	SILVER HOSPITAL Young Singles Hospital	$250
	BRONZE HOSPITAL Level 0 nil excess	Nil excess
	BRONZE HOSPITAL Level 1 nil excess	$250 singles - $500 families / couples / single parents
	BRONZE HOSPITAL Level 2 nil excess	$500 singles - $1000 families / couples / single parents
	SILVER HOSPITAL Young Singles Start Package (Hospital & Extras)	$250

5 - choose your preferred extras cover
	Cover Type*	Special Conditions
	I don't need Extras Cover
	GOLD EXTRAS
	Special Care Extras	Can only be combined with a Hospital cover. Available to Victorian Residents Only
	Standard Plus Extras	Available to Victorian Residents Only
	SILVER EXTRAS
	BRONZE EXTRAS

6 - transferring from another health fund
Current Health Fund
Cover Name
Membership Number
Date Joined	/ /
Date Paid To	/ /

7 - method of payment*
	Direct Debit from my bank/building society/credit union (direct debit attracts a cheaper premium)
	Automatic payment from credit card
	Cash, cheque, Bpay or Bill pay	Frequency  Monthly Quarterly Half-yearly Yearly
	Payroll deduction	Employer
For your security, a consultant will call you to obtain your direct debit or credit card details.

8 -additional information
Preferred Contact Day/Time*	Monday-Friday Monday Tuesday Wednesday Thursday Friday Business Hours 9am - 11am 11am - 1pm 1pm - 3pm 3pm - 5:30pm
Additional Information
How did you hear about Healthcare Assist?*	Please Select Current Healthcare Assist Member Google From a Healthcare Professional Yellow Pages From a Friend Other Internet Search Engine Other
Word Verification*	Type the characters you see in the image
	clearsubmit