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

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.