RACT Health Insurance Application Form

Application Form
1. I wish to (please tick)
Join RACT Health Insurance
Transfer from an existing RACT Health Insurance membership
Change my RACT Health Insurance cover
Are you an existing RACT member
Yes
No
RACT member number
You will need to be an RACT member to join RACT Health Insurance. I would like to
apply to become an RACT Access member (at no extra cost).
RACT Health Insurance member number (existing members only)
Cover or change of cover to commence from / /20
Cover does not commence until payment is received.
2. Type of cover
Single Family/Couple Single Parents
3. My details
Title Given names
Surname
Home address
Suburb/City State Postcode
Postal address (if different)
Suburb/City State Postcode
Date of birth / / Sex Male Female
Home phone
Day phone
Mobile
Fax
Email
Preferred form of written communication Email Mail
4. Partner authority (optional for applicant to sign)
I authorise the person identified as my partner/spouse on this application form to make
changes to this membership, including varying the level of cover.
Signed Date / /20
5. Other people to be covered
I confirm all people to be covered under my RACT Health Insurance membership are
citizens or permanent residents of Australia who have full Medicare eligibility.
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).
(include surname if different to applicant) Relationship Date of birth M/F
Given name / /
Educational institution
Given name / /
Educational institution
Given name / /
Educational institution
Given name / /
Educational institution
Hospital
Platinum Hospital
Level 0 nil excess
Level 1 ($250 maximum admission excess)
Level 2 ($500 maximum admission excess)
Gold Hospital
Level 0 nil excess
Level 1 ($250 maximum admission excess)
Level 2 ($500 maximum admission excess)
Silver Hospital
Level 0 nil excess
Level 1 excess ($250 maximum admission excess)
Level 2 excess ($500 maximum admission excess)
Bronze Hospital
Level 0 nil excess
Level 1 excess ($250 single and $500 families/couples/single parents)
Level 2 excess ($500 single and $1,000 families/couples/single parents)
Extras
Platinum Extras
Gold Extras
Silver Extras
Bronze Extras
6. Transferring from another health fund
Health fund
Cover name
Membership number
RPH0
RPH1
RPH2
RGH0
RGH1
RGH2
RSH0
RSH1
RSH2
RBH0
RBH1
RBH2
Date joined / / 20 Date paid to / / 20
If you’re transferring from another health fund, please attach a transfer certificate to your
application form. Or, you can complete the attached Transfer Certificate Request form if
you want RACT Health Insurance to terminate your membership and request a transfer
certificate on your behalf.
RPE
RGE
RSE
RBE
7. Direct credit of claims benefits
Please direct credit my benefits on paid accounts into the
bank/building society/credit union account nominated below.
BSB number -
Account number
Name(s) the account is held in
Bank Name
Branch
(If you’re unsure of the BSB number, please contact the bank where the account is held)
8. Method of payment
Direct debit from my bank/building society/credit union
(please complete Direct Debit Request form)
Automatic payment from credit card (please complete Credit Card Authorisation form)
9. Privacy
Personal information provided by you on this form is collected by RACT Health Insurance, or by
The Royal Automobile Club of Tasmania (“RACT”) on its behalf, and will be used to deliver the
health insurance products and services you request and, if requested by you, to apply for the
Australian Government Rebate on private health insurance on your behalf and to contact your
previous health fund to terminate your membership and request a transfer certificate. Failure to
provide all of the required information may prevent us from completing your requests. In addition,
we may use your contact details to notify you of news, special offers and information about our
products and services (unless you have opted out of receiving these communications by ticking
the relevant box at the end of this form). You can let us know at any time if you no longer wish
to receive these communications. Your consent to receiving these communications will remain
current until you advise us otherwise.
We may disclose personal information for the above purposes to our contracted service providers
(including RACT), government authorities and hospital, medical and ancillary service providers, as
well as to financial institutions to process payments. If you use this form to apply for RACT Access
membership, we will also disclose the personal information collected on this form to RACT for
that purpose. You are entitled to access any of your personal information and to make corrections
if needed (subject to some exceptions permitted by law).
RACT Health Insurance and RACT may from time to time exchange personal information collected
from you such as contact details, information about other persons covered by your policy and
your policy details (including to make sure that we each hold up-to-date contact details and to
tailor marketing sent to you), unless you have opted out of this by ticking the relevant box at the
end of this form. You can let us know at any time if you do not want your personal information
shared between RACT Health Insurance and RACT in this way. If you provide personal information
about another person on this form, you warrant that this information is provided with the consent
of the individual to whom it relates and that you have the authority to act on their behalf.
10. Declaration (applicant to sign)
The signing of this application and the payment of any premium shall constitute agreement to
the above privacy notice and conditions laid down by the regulations in force at this time or as
may be amended from time to time. I understand: proof of identity including age may be required
to confirm the details of persons listed on this application, the rulings regarding pre-existing
conditions/illnesses, waiting periods and the conditions of membership. I declare the above
statements/information to be true and correct.
Signed Date / / 20
Please fill in forms to claim the Australian Government Rebate on private health insurance and
pay by direct debit.