Private Health Insurance Rebate change form

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* Based on an Australian Government Rebate of %, % LHC loading, $ excess for a in .

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The rebate is the amount the Australian Government contributes to the cost of private health insurance premiums. You can choose to receive the rebate upfront, as a reduction of your premium or at tax time.

Please complete this form if you wish to change your rebate tier. Review the income thresholds and rebates to find the tier that matches your current income.

Please note that nominating a rebate tier is voluntary. Any rebate (or liability) will be adjusted by the ATO when you lodge your tax return.

If you have not previously claimed the rebate, we will contact you to request an Application to receive the Australian Government Rebate on Private Health Insurance as a reduced premium form (MS006).

Full name of primary member

Membership number

Date of birth

Email (Please provide the same email linked to your membership. We may contact you by email if we need additional details to complete your request.)

Address

Select a start date for claiming the rebate tier. Choose a future date at least 14 days in advance, or backdate it to the start of the current financial year

Declaration

I declare that the above information is true and correct. I hereby authorise the above rebate change to be applied to my Membership.

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