Form



	Please indicate how you prefer to receive our information	EmailRegular Post
	How did you find out about Health Link Consultants?
	Title
	Given name
	Surname
	Address
	Town/Suburb
	Postcode
	State
	Home phone
	Work phone
	Email
	Employer
	Status
	Your Date of Birth Your Date of Birth is required to calculate your premiums to see if Lifetime Health Cover Applies.
	Are you entitled to full Medicare benefits? In order to obtain full Medicare benefits you must be a permanent Australian Resident and a holder of a Medicare Card. If not, please contact our office on 1800 808 026 or visit our website and view Overseas Visitors Cover.	YESNO
	Do you earn over $70,000 per year? The Medicare Levy Surcharge is a Federal Government initiative designed to encourage high income earners to take out health insurance. It applies to those earning a taxable income of over $70,000 per year for singles and $140,000 for couples/families. If you do not hold private hospital cover and you are a high income earner you will be charged an additional 1% surcharge on your Medicare Levy when your tax return is assessed.	YESNO
	What is your primary reason for taking out Health Cover?



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