Request for Assistance

Member No. (if known)

First Name *

Last Name *

Street Address *

Suburb *

State *

Postcode *

Phone Number *

Email Address *

The Assistance Requested is for

Private Prescription (Please attach Official Pharmacy Receipt)Medically Required Capital Items (Please attach a doctor’s letter (except for mobility or hearing aids) and a Tax Invoice)Newborn Assistance (Please attach certified Birth Certificate)Funeral Assistance (Please attach certified Death Certificate)

Significant and Multiple Medical conditions (Please attach a doctor’s letter, along with a written declaration confirming that you have not received any alternate financial assistance)

*Types of costs incurred in living with the significant and multiple medical conditions (s): *

Approximate cost for month $

Attach Documents Here

You may upload your document (s) here.

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Bank Account Details (Member's Account Only)

BSB *

Account Number *

Account Name *

Message or Comment

I certify that no government assistance (e.g. any Medicare benefits, NDIS, Home Care & Aged Care Packages) or private health fund support has been received. *

I certify that assistance requested is only for persons covered under my membership. *

Declaration

Signed *

Draw signature|Type signatureClear

Date *