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Permanent/Residential address
Details of all people covered by the policy (do not include yourself)
Family name Given name(s) Date of birth Sex/Gender Relationship to applicant
Dependent child
M F Y N
M F Y N
M F Y N
M F Y N
M F Y N
M F Y N
Are all the people on the policy listed on a Medicare card or entitled to a Medicare card? Yes No
For a definition of dependent child and for details on Medicare card entitlement, please refer over the page.
Declaration Privacy notice - Your personal information is protected by law, including the Privacy Act 1988, and is collected
by the Australian Government Department of Human Services for the assessment and administration of
I declare that the information I have provided is correct. I understand
payments and services. This information is required to process your application or claim.
that there are penalties for giving false or misleading information.
Your information may be used by the department or given to other parties for purposes of research,
investiagion or where you have agreed or it is required or authosied by law.
Signature
You can get more information about the way in which the Department of Human Services will manage your
personal information, including our privacy policy at www.humanservices.gov.au/privacy or by requesting a
copy from the department.
Date
Sign and email this form to info@ahm.com.au or post to ahm health insurance, Locked Bag 4, Wetherill Park NSW 2164
Dependent child
A child is dependent if the child is under the age of 25 and is covered by your ahm Insurance policy as a Dependant.