Download the application form - RACT

Application Form1. I wish to (please tick)Join RACT Health InsuranceTransfer from an existing RACT Health Insurance membershipChange my RACT Health Insurance coverAre you an existing RACT member?Yes RACT member numberNo You will need to be an RACT member to join RACT Health Insurance. I would like toapply 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 / /20Cover does not commence until payment is received.2. Type of coverSingle Family/Couple Single Parents3. My detailsTitle Given namesSurnameHome addressSuburb/City State PostcodePostal address (if different)Suburb/City State PostcodeDate of birth / / Sex Male FemaleHome phoneDay phoneMobileFaxEmailPreferred form of written communication Email Mail4. Partner authority (optional for applicant to sign)I authorise the person identified as my partner/spouse on this application form to makechanges to this membership, including varying the level of cover.Signed Date / /205. Other people to be coveredI confirm all people to be covered under my RACT Health Insurance membership arecitizens or permanent residents of Australia who have full Medicare eligibility.Note: Children under 21 are covered under family memberships. Children over 21 and under 25are covered if they are single and undertaking a full-time apprenticeship, full-time traineeship orfull-time study at eligible educational institutions (please list below).(include surname if different to applicant) Relationship Date of birth M/FGiven name / /Educational institutionGiven name / /Educational institutionGiven name / /Educational institutionGiven name / /Educational institutionHOSPITALPlatinum HospitalLevel 0 nil excessLevel 1 ($250 maximum admission excess)Level 2 ($500 maximum admission excess)Gold HospitalLevel 0 nil excessLevel 1 ($250 maximum admission excess)Level 2 ($500 maximum admission excess)Silver HospitalLevel 0 nil excessLevel 1 excess ($250 maximum admission excess)Level 2 excess ($500 maximum admission excess)Bronze HospitalLevel 0 nil excessLevel 1 excess ($250 single and $500 families/couples/single parents)Level 2 excess ($500 single and $1,000 families/couples/single parents)EXTRASPlatinum ExtrasGold ExtrasSilver ExtrasBronze Extras6. Transferring from another health fundHealth fundCover nameMembership numberDate joined / /20 Date paid to / /20RPH0RPH1RPH2RGH0RGH1RGH2RSH0RSH1RSH2RBH0RBH1RBH2If you’re transferring from another health fund, please attach a transfer certificate to yourapplication form. Or, you can complete the attached Transfer Certificate Request form ifyou want RACT Health Insurance to terminate your membership and request a transfercertificate on your behalf.RPERGERSERBE7. Direct credit of claims benefitsPlease direct credit my benefits on paid accounts into thebank/building society/credit union account nominated below.BSB number -Account numberName(s) the account is held inBank NameBranch(If you’re unsure of the BSB number, please contact the bank where the account is held)8. Method of paymentDirect 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. PrivacyPersonal information provided by you on this form is collected by RACT Health Insurance, or byThe Royal Automobile Club of Tasmania (“RACT”) on its behalf, and will be used to deliver thehealth insurance products and services you request and, if requested by you, to apply for theFederal Government Rebate on your behalf and to contact your previous health fund to terminateyour membership and request a transfer certificate. Failure to provide all of the requiredinformation may prevent us from completing your requests. In addition, we may use your contactdetails 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 atthe end of this form). You can let us know at any time if you no longer wish to receive thesecommunications. Your consent to receiving these communications will remain current until youadvise 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, aswell as to financial institutions to process payments. If you use this form to apply for RACT Accessmembership, we will also disclose the personal information collected on this form to RACT forthat purpose. You are entitled to access any of your personal information and to make correctionsif needed (subject to some exceptions permitted by law).RACT Health Insurance and RACT may from time to time exchange personal information collectedfrom you such as contact details, information about other persons covered by your policy andyour policy details (including to make sure that we each hold up-to-date contact details and totailor marketing sent to you), unless you have opted out of this by ticking the relevant box at theend of this form. You can let us know at any time if you do not want your personal informationshared between RACT Health Insurance and RACT in this way. If you provide personal informationabout another person on this form, you warrant that this information is provided with the consentof 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 tothe above privacy notice and conditions laid down by the regulations in force at this time or asmay be amended from time to time. I understand: proof of identity including age may be requiredto confirm the details of persons listed on this application, the rulings regarding pre-existingconditions/illnesses, waiting periods and the conditions of membership. I declare the abovestatements/information to be true and correct.Signed Date / /20Please fill in forms to claim the Federal Government 30% Rebate on private health insuranceand pay by direct debit.

Application to receive the Federal Government RebateDirect Debit RequestTransfer Certificate RequestApplication to receive the Federal Government 30% Rebate on private health insurance as a reduced premium• Complete this registration form and lodge it with GMHBA Limited to receive the Federal Government 30% Rebate onprivate health insurance as a reduced premium.• This application must be completed in black pen using block letters.• All the people listed on the policy must be eligible to claim Medicare for you to receive the Federal Government 30%Rebate on private health insurance as a reduced premium.• If at any stage you wish to stop receiving the Federal Government 30% Rebate on private health insurance as areduced premium, you must notify GMHBA Limited as soon as possible.• If you do not complete this application, higher membership premiums will apply than those that appear in our rateinserts. Call us on 13 27 22 for more information.• Employers and trustees of organisations cannot claim the Federal Government 30% Rebate on private health insurancepolicies paid on behalf of employees.Name of private health fund issuing the policy to which this application relates:GMHBAAre you covered by this policy? Yes NoAre all the people on the policy listed on aYes NoMedicare card or entitled to a Medicare card?You are entitled to a Medicare card if you are a person who lives in Australia; you are an Australian citizen; a holder ofa permanent resident visa; a New Zealand citizen, or, in some cases an applicant for a permanent resident visa. Anyenquiries about Medicare eligibility can be made at any Medicare office or by phoning 132 011 for the cost of a local call.Your full name exactly as it appears on your Medicare card:Medicare number Valid to /The information provided on this form will be used for the purposes of registering you for the Federal Government 30%Rebate on private health insurance. Its collection is authorised by law, and information collected may be disclosed to theDepartment of Health and Ageing, the Health Insurance Commission, and the Australian Taxation Office.DeclarationI declare that the information I have provided is correct including details of dates ofbirth on this application form. I understand that there are penalties for giving false or misleading information.Signed Date / /20Please include this registration form with your applicationIf you need to know more about the Federal Government 30% Rebate on private health insurance and reducedpremiums through your health fund, contact the Department of Health and Ageing or visit www.health.gov.auDate / /20RACT Health Insurance member numberMember nameHome addressSuburb/City State PostcodeName(s)I/We authorise and request GMHBA trading as RACT Health Insurance User ID No. 015617 to arrange for funds to bedebited from my/our account at the financial institution identified below and as prescribed below through the BulkElectronic Clearing System (BECS) and to apply these funds in payment of the member’s premium up to the next directdebit date, including any arrears of premium. This authorisation is to remain in force in accordance with the termsdescribed in the Direct Debit Request Service Agreement.Bank/Financial InstitutionBank nameBank addressAccount nameBSB number -Account numberFrequency Fortnightly Monthly QuarterlyHalf-yearly YearlyExcluding the 29th, 30th & 31st of any month, the first direct debit is to take place on/ /20I/We have read and accept the terms of the Direct Debit Request Service Agreement as may be amended fromtime to time by GMHBA trading as RACT Health Insurance and authorise the following:1. GMHBA trading as RACT Health Insurance to verify the details of the above mentioned account withmy/our financial institution2. My/Our financial institution to release information allowing GMHBA trading as RACT Health Insurance to verifythe above mentioned account details.Signature(s) (of account holder/s)RACT Health Insurance brought to you by GMHBA LimitedGPO Box 1292 HOBART TAS 7001Tel: 13 27 22 Fax: (03) 6232 0020Email: healthinsurance@ract.com.au Website: ract.com.au/healthinsuranceSigned Date / /20Please complete this form if you want RACT Health Insurance to terminate your membership with another health fund andrequest a transfer certificate and claims history on your behalf. This form must be signed by the member who has legalresponsibility for membership of your previous fund.Health fundMembership numberMember nameHome addressSuburb/CityPostcodeI authorise RACT Health Insurance to cancel my Hospital only Extras onlyCombined cover with your fund from:Date / /20Signed Date / /20Please refund my premiums paid in advance of the cancellation date and send a transfer certificate and claims historyfor all people covered under my membership to RACT Health Insurance.Remember! Continuity of a member’s/partner’s certified age at entry (CAE) is possible when transferring from anotherAustralian registered health fund under Lifetime Health Cover.Please do not contact me further about this request.RACT Health Insurance brought to you by GMHBA LimitedGPO Box 1292 HOBART TAS 7001Tel: 13 27 22 Fax: (03) 6232 0020Email: healthinsurance@ract.com.au Website: ract.com.au/healthinsuranceSigned Date / /20

Credit Card AuthorisationDate / /20RACT Health Insurance member numberMember nameHome addressSuburb/City State PostcodeI hereby authorise GMHBA trading as RACT Health Insurance to charge my credit cardon this occasion for the amount of $RACT Health Insurance brought to you by GMHBA LimitedGPO Box 1292 HOBART TAS 7001Tel: 13 27 22 Fax: (03) 6232 0020Email: healthinsurance@ract.com.au Website: ract.com.au/healthinsuranceApplicationChecklist:Application formApplication to receive the FederalGovernment Rebate on private healthinsurance as a reduced premium formDirect Debit or Credit CardAuthorisation formTransfer Certificate Request form(if transferring from another health fund)Once we’ve processedyour membership we’ll:Send your welcome pack andmembership card.Start your direct debits (if applicable.)For transferring members, send yourTransfer Certificate Request to yourprevious health fund. Please send yourtransfer certificate and claims history tous as soon as you receive it from yourprevious health fund. Any premiumspaid in advance will be refunded.automaticallyMonthly Quarterly Half-yearly YearlyUntil instructed by me in writing to cease deductions.I understand that the first credit charge will occur on 01/ /20(first working day of the month).I also authorise GMHBA trading as RACT Health Insurance to charge my credit card such amount as is required to paythe member’s premium up to the next charge date. If the premium changes or payments are in arrears, I authoriseGMHBA trading as RACT Health Insurance to alter the amount from the appropriate date in accordance with suchchanges.Alterations/cancellations to membership or account details must be received, in writing, on the prescribed form/s at least7 days before the next scheduled direct debit deduction date.A refund of premiums cannot be issued within 14 days of the debit date. This allows sufficient time for the financialinstitution to advise GMHBA trading as RACT Health Insurance of any debit deduction dishonour.After two consecutive dishonours GMHBA trading as RACT Health Insurance will remove the membership from the debit scheme.How did you hear about us?From time to time, RACT Health Insurance contacts members (by phone, email, post) to notify them ofnews, special offers and information about our products and services. If you do not wish to receivethese communications, please cross this box.RACT Health Insurance and RACT may from time to time exchange personal information collectedfrom you, as described in section 9 of the application form. If you do not wish us to share yourinformation in this way, please cross this box.Please keep the Member Guide with your other RACT Health Insurance documentsType of credit cardMastercard Visa CardCard numberExpiry date /20Cardholder’s nameCardholder’s signature

RACT OfficesHobartCnr Murray & Patrick StsLauncestonCnr York & George StsDevonport119 Rooke Street MallBurnie24 North TerraceRosny ParkRosny Mall, 2 Bayfi eld StreetGlenorchyCnr Main Road & Terry StreetKingstonShop 49A Channel Court13 27 22ract.com.au/healthinsuranceFax: (03) 6232 0020Postal Address: GPO Box 1292Hobart, Tasmania 7001Brought to you by GMHBA Limited.