Do you have private health insurance?

We’ve received many great applications
for Access and are processing these now.
Please note to be eligible for this program
you must have a level of private health cover.

PERSONAL INFORMATION

 Male Female
Partnership status  Single married de-facto divorced other

PROCEDURE REQUESTED FOR ACCESS

 BARIATRIC SURGERY HERNIA REPAIR UPPER GIT ENDOSCOPY BREAST LUMPS/ BENIGN BREAST SURGERY BREAST IMPLANT REVISION SURGERY BREAST REDUCTION SURGERY POST WEIGHT LOSS SURGERY

HEALTH FUND INFORMATION

Does your fund participate in known gap?  Yes No
If you do not have private cover, are you intending on getting it in the near future?  Yes No

BENEFITS SECTION

Do you currently receive any of the following benefits?

 Aged Pension Austudy Carer’s Payment Commonwealth Concession Card from Veteran’s Affairs Disability Support Pension Family Tax Benefit Part A or B Health Care Card Low Income Family Supplement Newstart Allowance Parenting Payment Rent Assistance Youth Allowance None

OTHER FINANCIAL INFORMATION

Do you own, or jointly own any property?  Yes No

Select the range of your household income:

 0- $40 000 $40 000 - $80 000 $80 000 - $120 000 $120 000- above

YOUR STORY - WHY YOU WOULD BENEFIT

To support your application you are welcome to submit the following

  • Statement of financial hardship
  • Documentary proof of financial hardship and/or low income status

PLEASE NOTE : Documentary proof of financial hardship and or low income may be required to be submitted on request