Get Gym Membership Form Pdf

Exercise Gym benefits authorisation claim form Complete and send to HCF GPO Box 4242 Sydney NSW 2001 If your extras cover includes benefits for HCF approved health management programs you can claim towards the costs of an exercise program or gym membership. To accord with private health insurance legislation exercise and gym fees are only claimable when the exercise program is designed to address or improve a specific health or medical condition. Please ask your GP or medical specialist to complete section 2 and submit the completed form to HCF along with your receipts/invoices. 1. Claimant s details PLEASE USE CAPITAL LETTERS Membership No* Date of birth / Title First Name Surname Is this claim the result of an accident or trauma Yes If yes please give the date of the event Is the claimant entitled to any form of compensation damages or payment as a result of the accident or event If yes please provide brief details 2. To be completed by your Medical Practitioner Medical Practitioner s Name Telephone number including area code Medicare provider number Postcode Please indicate the patient s medical condition that this exercise regime is addressing months Declaration to be completed by the Medical Practitioner I declare that the information I have provided is true and accurate. Date I declare all information provided in support of this claim to be true and correct and that all persons covered by this policy whose privacy rights may be affected have been made aware of the HCF Privacy Policy. I understand that extras benefits cannot be claimed from HCF that have been or will be claimed from Medicare unless permitted by law. I declare that the patient was not aware of any symptom related to the condition for which benefits are claimed before joining HCF or transferring to the current level of cover. I acknowledge that HCF deals with personal information of all members in accordance with its privacy policy. I authorise and have the consent of the patient where necessary to authorise HCF to contact the provider and to access any information needed to verify this claim* Signature must be of the Policy holder or Partner listed on Policy PRIVACY How HCF collects uses keeps and secures personal information is described in the HCF Privacy Policy. For a copy of this policy visit a branch call 13 13 34 or log onto www. hcf*com*au Call HCF Member Information 13 13 34 The Hospitals Contribution Fund of Australia Limited* ABN 68 000 026 746 AFSL 241 414 HEAD OFFICE 403 George Street Sydney NSW 2000 Telephone 13 13 34. Postal Address GPO Box 4242 Sydney NSW 2001 E-mail service hcf*com*au Internet www. hcf*com*au HCF EXERCISE AND GYM BENS FORM 0513. 1. Claimant s details PLEASE USE CAPITAL LETTERS Membership No* Date of birth / Title First Name Surname Is this claim the result of an accident or trauma Yes If yes please give the date of the event Is the claimant entitled to any form of compensation damages or payment as a result of the accident or event If yes please provide brief details 2. To be completed by your Medical Practitioner Medical Practitioner s Name Telephone number including area code Medicare provider number Postcode Please indicate the patient s medical condition that this exercise regime is addressing months Declaration to be completed by the Medical Practitioner I declare that the information I have provided is true and accurate.