Applicants should nominate a rebate tier based on their estimated income

Indicate you have read and understood the declarations

Application to receive the Australian Government Rebate on Private Health Insurance as a reduced premium

All the people listed on the policy must be eligible to claim Medicare for you to receive the rebate as a reduced premium.

If at any stage you wish to nominate a new income tier or stop receiving the Australian Government Rebate as a reduced premium, you must notify your health fund as soon as possible.

(If No) Applicants not covered by the policy cannot claim the Australian Government Rebate on Private Health Insurance (excluding child only policies) and employers and trustees of organisations cannot claim the Australian Government Rebate on Private Health Insurance on policies paid on behalf of employees.

Your full name as it appears on your Medicare card

Please enter dd/mm/yyyy (interim and reciprocal cards) or mm/yyyy for permanent residents

Provide details of all people covered by the policy (do not include yourself).

All people listed on the policy must be eligible to claim Medicare for you to receive the rebate as a reduced premium. If you are unsure whether you are eligible for Medicare, go to more information.

For more information about the Australian Government Rebate on Private Health Insurance, go toprivatehealth.gov.auQuestions about Medicare eligibility can be made at any Human Services Service Centre or by calling 132 011.

Note:Call charges apply calls from mobile phones may be charged at a higher rate.

Applicants must nominate a rebate tier based on their estimated income for the financial year from the rebate tier below.

Your personal information is protected by law (including thePrivacy Act 1988) and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. This information is required to process your application or claim.

Your information may be used by the department, or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations).

You can get more information about the way in which the department will manage your personal information, including their privacy policy, at

Please check this box to indicate you have read and understood the declarations.

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minDivsCount) $(div + visibleDivsCount).hide(); $(div + visibleDivsCount + :input).val(); $(div + visibleDivsCount + input:radio).attr(checked, false); visibleDivsCount -= 1; $([id$=_uxPersonCount]).val(visibleDivsCount); if (visibleDivsCount

keyObj2.length) var biggestKey = keyObj1.length; else var biggestKey = keyObj2.length; var changed = ; for (var i = 0; i

; if (changed != ) $(.ChangedValues).val(table); // In case user changes their mind and goes back to change the data if (enteredPostalAddressChanged) myObj2[uxPostalAddressLine1] = ; myObj2[uxPostalAddressLine2] = ; myObj2[uxPostalAddressPostcode] = ; myObj2[uxPostalAddressState] = ; myObj2[uxPostalAddressSuburb] = ; else if (originalPostalAddressChanged) myObj1[uxPostalAddressLine1] = ; myObj1[uxPostalAddressLine2] = ; myObj1[uxPostalAddressPostcode] = ; myObj1[uxPostalAddressState] = ; myObj1[uxPostalAddressSuburb] = ; function concatArray() var concatArrayValues = ; var family = ; var givenName = ; var dateOfBirth = ; var sexMale = ; var sexFemale = ; var dependentTrue = ; var dependentFalse = ; $(.personConcat :input).each(function() var code = $(this).attr(name); if (code.indexOf(gender) !== -1) if($(this).is(:checked)) concatArrayValues[$(this).attr(name)] = $(this).val(); else if (code.indexOf(Dependent) !== -1) if($(this).is(:checked)) concatArrayValues[$(this).attr(name)] = $(this).val(); else concatArrayValues[$(this).attr(name)] = $(this).val(); ; if (code.indexOf(FamilyName) !== -1) family += $(this).val() + ; else if (code.indexOf(GivenName) !== -1) givenName += $(this).val() + ; else if (code.indexOf(DateOfBirth) !== -1) dateOfBirth += $(this).val() + ; else if (code.indexOf(gender) !== -1) if($(this).is(:checked)) var gender = $(this).val(); console.log(gender, gender); if (gender == Male) sexMale += X + ; sexFemale += + ; else sexMale += + ; sexFemale += X + ; else if (code.indexOf(Dependent) !== -1) if($(this).is(:checked)) var dependent = $(this).val(); if (dependent == Yes) dependentTrue += X + ; dependentFalse += + ; else dependentTrue += + ; dependentFalse += X + ; ); var values = JSON.stringify(concatArrayValues); $(.uxMoreThanFive).val(values); $(.FamilyNameConcat).val(family); $(.givenNameConcat).val(givenName); $(.dateOfBirthConcat).val(dateOfBirth); $(.sexMaleConcat).val(sexMale); $(.sexFemaleConcat).val(sexFemale); $(.dependentTrueConcat).val(dependentTrue); $(.dependentFalseConcat).val(dependentFalse); ; $(function () $([id$=_uxDeclarationCheckBox]).click(function () if ($(this).is(:checked)) $([id$=_uxViewFormButton]).removeAttr(disabled); $([id$=_uxViewFormButton]).focus(); else $([id$=_uxViewFormButton]).attr(disabled, disabled); concatArray(); ); ); $([id$=_uxPostalAddressSameAsHomeCheckbox]).click(function () if ($(this).is(:checked)) $([id$=_uxPostalAddressPanel]).addClass(hide); else $([id$=_uxPostalAddressPanel]).removeClass(hide); ); ; , 150); );