APPLICATION FORM

Please fax or mail pages 1 & 2 only. Fax: 1300 735 322 Mail: Reply Paid 2021, Moorabbin , Vic 3189
iSelect Health Pty Ltd ABN 87 088 749 955
KYLLAN
OFFICE USE ONLY
MEMBERSHIP NUMBER ISSUED BY FUND iSelect Client No. 9611953
New Membership Transfer Membership from another Fund
(Complete Transfer Authority on following page)
Mr Domma Raju Santhosh Varma
Mr/Mrs/Ms/Miss/Other: __________ Surname: ______________________________ Given name/s: _______________________
Date of Birth: 30-Dec-1984 (DD/MM/CCYY) Occupation:
Address: Unit 50, 13 Bryant Street
Town/Suburb: Rockdale State: NSW Postcode: 2216
Phone: Home: ( ) Work: ( ) Mobile: 0414974512
Email address: santhosh88@gmail.com

OTHER PERSONS TO BE COVERED

Given name & Initial Surname Date of birth Sex Relationship to Member Pre-existing conditions

Student Dependant cover where the student is 21 years or over

Student Dependant Declaration 1 Student Dependant Declaration 2
Name: Name:
Educational Institution: Educational Institution:
Student Id Number: Student Id Number:
Full-time Student Part-time Student Full-time Student Part-time Student
Date Study Commenced: Date Study Commenced:
I authorise The Doctors Health Fund limited to give (write persons full name)

access to my membership, This will enable them to make enquiries and changes to the policy with the exception of cancelling the policy.

SELECTED PRODUCT/S Smart Starter $500 Excess AND Essential Extras

Type of Cover Single Male
Excess Amount $500
Cover commences on ______________________ (nominated date)
Conditional on receipt of payment within 14 days. Base Premium Quoted: $_________________
Lifetime Loading (if applicable) $ ________________
80.05 monthly with 30.0%
Total Premium $___________________
Premium quoted valid to 31/03/11

I qualify for membership of the Doctors’ Health Fund in the following category, please tick appropriate box
Doctor, medical student, overseas trained doctor (write your hospital, medical practice or university)
registered for AMC exams
Employee of a medical practice or association ( write your hospital, medical practice or university)

The partner, child, grandchild,sibling, former partner, or the partner of an adult child of a person in the above categories

DECLARATION (PLEASE SIGN THIS SECTION WHERE INDICATED)

By submitting this application form, I acknowledge that I have read and understood and agree to, the Doctors’ Health Fund rules and conditions as
defined in the Policy brochure pdf sent with this application form. I declare that the information provided on this form is true, correct and complete and
will notify The Doctors’ Health Fund of any changes. I agree to be bound by the Doctors’ Health Fund by-laws, which may change from time to time and
may effect my health cover. I understand that waiting periods may also apply
Proof of identity including the age of myself and my dependants, may be required. The date of birth of myself and my partner and any Lifetime Health
Cover Loading information given on this application is used to calculate my membership fee and if found to be incorrect the Doctors’ Health Fund may
retrospectively change my fee and adjust my date paid to. This application is subject to processing and approval by the Doctors’ Health Fund and I/We
are not automatically covered by the Doctors’ Health Fund by submitting this application, The Doctors’ Health Fund will notify you whether it has been
accepted or rejected. If the Doctors’ Health Fund accepts this application, then my/our cover will commence from the nominated date, or the date the
Doctors’ Health Fund receives this form.

Signature x Date:
Please fax or send pages 1 & 2 only Fax: 1300 735 322 Mail: Reply Paid 2021, MOORABBIN, VIC 3186 1
or call 1300 735 255
 APPLICATION FORM

MEDICARE ELIGIBILITY
My Medicare card is Green – Full unrestricted access Yellow Reciprocal card – restricted Blue Interim card – unrestricted
access until expiry date access until expiry date
My Medicare card no is Valid To NO MEDICARE CARD

FEDERAL GOVERNMENT REBATE

Please complete this section in full to receive the Federal Government 30% Rebate on private health
insurance as a reduced premium. If you do not complete this section, full membership fees apply.
Are all people nominated on Page 1 on this membership eligible for full Medicare benefits?
Yes If YES please complete the remainder of this section.
No If NO you cannot apply for the rebate until you obtain a card from Medicare.
If NO, employers and trustees of organisations cannot claim the Federal
Are you covered on this membership? Yes No Government 30% Rebate on policies paid on behalf of employees.
Your Medicare Card No. Valid To Date premium reduction to commence / / (Start date of this policy)

Your name exactly as it appears on your Medicare card

Some of 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 will be disclosed to the Department of Health and Aged Care, the Health Insurance Commission and the Australian Taxation Office.
Signature x Date:

PAYMENT OPTIONS Direct debit - select from option 1 or 2 Account Notice (tick box)

OPTION 1 - DIRECT DEBIT FROM BANK /BUILDING SOCIETY/CREDIT UNION ACCOUNT

I would like the Doctors’ Health Fund to set up automatic payments of my contributions

Name of Financial Institution Branch

Account name BSB No. Account No.

-
Tick payment frequency and date of payment Monthly Quarterly Half Yearly Yearly (nominate a day from 1-27th)

I/We request The Doctors’ health Fund Limited (ID No 324455) to arrange a debit from the account nominated above in accordance with the terms and
conditions of the Direct Debit Request Service Agreement in the Fund’s product brochure and on the Fund’s website.

Account Holders
signature/s Date:
Date:
OPTION 2 - CREDIT CARD AUTHORITY I would like the Doctors’ Health Fund to set up automatic payments from my credit card
Type of card (please tick) Visa MasterCard

Card Holder's Name

Card No. Expiry Date

Card Holder signature Date:

DIRECT CREDIT OF CLAIMS I request Doctors’ Health Fund Limited to credit my/our nominated account with any amount
which may be payable by the fund in respect of a claim or benefit on my membership.
Name of Bank, Credit Union or Building Society

Name on a/c BSB No. - Account

No.
Signature x Date:

TRANSFER CERTIFICATE REQUEST: PLEASE COMPLETE IF YOU ARE TRANSFERRING FROM ANOTHER FUND
Name Fund Membership No.
Type of Cover: single / single parent / couple / family (circle one) extras only / hospital only / extras and hospital cover (circle one)
Date joined: Date cover ceased:
___________________ _________________
I hereby authorise Doctors’ Health Fund to cancel my membership with
your organisation and obtain details about that membership

Signature x Date
: