Do you have private health insurance?

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

PERSONAL INFORMATION

 Male Female

Partnership status  Single married de-facto divorced other

PROCEDURE REQUESTED FOR ACCESS

 BARIATRIC SURGERY BREAST REDUCTION SURGERY POST WEIGHT LOSS SURGERY SHOULDER REPLACEMENT SURGERY ELBOW REPLACEMENT SURGERY HIP SURGERY KNEE 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 total household income (per annum)*:

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

Upload your supporting documents (if any)

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

* this field is compulsory.