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)Mobility Aids (Please attach Tax Invoice)Hearing aids (Please attach Tax Invoice)Newborn Assistance (Please attach Birth Certificate)Funeral Assistance (Please attach Death Certificate)Healthy Lifestyle Assistance

Chronic Medical Illness (Please attach annually updated Doctor's letter)

*Types of costs incurred in living with the chronic condition (s)

Approximate cost for month $

Attach Documents Here

You may upload your document (s) here.

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Bank Account Details

BSB *

Account Number *

Account Name *

Message or Comment

Declaration

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

Signed *

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Date *

Verification *