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

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

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.