Do you have private health insurance?

Yes No

Thank you for applying to The ACCESS Program. Please Note: to be eligible for this program, you must have Private Health Cover

    PERSONAL INFORMATION

    MaleFemale

    Partnership status Singlemarriedde-factodivorcedother

    PROCEDURE REQUESTED FOR ACCESS

    BARIATRIC SURGERYBREAST REDUCTION SURGERYPOST WEIGHT LOSS SURGERYSHOULDER REPLACEMENT SURGERYELBOW REPLACEMENT SURGERYHIP SURGERYKNEE SURGERY

    HEALTH FUND INFORMATION

    Does your fund participate in known gap?* YesNo

    If you do not have private cover, are you intending on getting it in the near future?* YesNo

    BENEFITS SECTION

    Do you currently receive any of the following benefits?*

    Aged PensionAustudyCarer’s PaymentCommonwealth Concession Card from Veteran’s AffairsDisability Support PensionFamily Tax Benefit Part A or BHealth Care CardLow Income Family SupplementNewstart AllowanceParenting PaymentRent AssistanceYouth AllowanceNone

    OTHER FINANCIAL INFORMATION

    Do you own, or jointly own any property?* YesNo

    Select the range of your total household income (per annum)*:

    The ACCESS Program is only available to Applicants with a total household income of $120,000 per annum or less. However, an ACCESS surgeon may be willing to discuss your requested procedure with you at a reduced rate. If you have any questions, please email us at info@ishc.com.au.

    YOUR STORY - WHY YOU WOULD BENEFIT

    PLEASE NOTE : Documentary proof of financial hardship and or low income may be required to be submitted on request. Once your application has been received, you will be contacted to provide documentation if required.

    * this field is compulsory.

    PLEASE NOTE:

    • The Access Program does not cover Breast Augmentations (Breast Lifts, Implants).
    • Revision Surgery is not covered by the Access Program.
    • Patients who have had previous Bariatric Surgery are not eligible for Bariatric Surgery as part of the Access Program.

    COMMUNICATION ON SOCIAL MEDIA:

    If accepted into the Access Program, we request that patients do not reveal the name of their surgeon, the procedures being performed or the cost of their surgery on social media, through private messaging or in support groups.
    This is to protect the Surgeons who generously give their time to the Access Program.