Send your claim & receipts/accounts to:
PRINT
Email: [email protected]
Fax: 1300 309 704
Post: Reserve Bank Health Society
Locked Bag 23, WOLLONGONG DC NSW 2500
Web: www.myrbhs.com.au
Claim Form
J O H N
PLEASE USE A BLACK PEN AND PRINT IN CAPITAL LETTERS INSIDE THE BOXES. EXAMPLE:
1.
YOUR DETAILS
Membership Number
First Name
Service TypeCode
Acupuncture
ACU
Chiropractic
CHI
Dental (use 3 number
item code from your receipt)
Middle Name
Massage (remedial)
Naturopath
Optical
Osteopathy
Pharmacy
Physiotherapy
Podiatry
Surname
2.CHANGE OF CONTACT DETAILS or PAYMENT METHOD Click the checkbox OR leave it blank if unchanged.
I have changed my contact details
I would like my claim paid into a new bank account
(If yes, please complete section 5 on the reverse)
(If yes, please complete section 6 on the reverse)
REM
NAT
OPT
OST
PHA
PHY
POD
If your service isn’t listed or you’re not sure,
just leave this blank.
3.CLAIM DETAILS
Please include itemised receipts / accounts with your claim form
Patient First Name
Patient DOB (ddmmyy)
Service Date (ddmmyy)Cost of Service ($)
Provider Surname
Provider Number
Service Type
E.G.
J O H N
2 1 0 7 8 2
0 8 1 1 1 0
0 1 2 5 .. 5 0 S M I T H
0 1 1 2 6 3 2 B
C H I
1
.
2
.
3
.
4
.
5
.
6
.
Reserve Bank Health Society Limited. A Registered Private Health Insurer. ABN 91 087 648 735.
4.CHANGE OF CONTACT DETAILS (Only complete if your contact details have changed)
Street Address
Suburb
State
Post Code
Email Address
Home Phone Number
Mobile Number
Fax Number
-
-
5.DIRECT CREDIT DETAILS (Only complete if your bank details have changed)
Bank Name
BSB Number
Account Name
Account Number
6.
MAKING A CLAIM
Simply choose the option that best suits you. You can swipe your membership card at the service provider or claim via email, web, fax or post.
Email:
Web:
Fax:
Post:
[email protected]
www.myrbhs.com.au
1300 309 704
Reserve Bank Health Society
Locked Bag 23 WOLLONGONG NSW 2500
We can deposit your benefits straight into your bank account or mail you a cheque.
7.
INSTRUCTIONS
Receipts/accounts must accompany all claim forms. They should be fully itemised including the patients’ name, and the name, address and details of your provider. Benefits
are only paid on claims that are less than two years old (24 months).
Please note - Receipts will not be sent back with your remittance advice but will be filed electronically in your member file. The remittance advice will detail all costs from your
claims and the benefits paid. If you need a copy of your receipts in the future they can be provided to you at no charge.
DECLARATION & PRIVACY STATEMENT
I declare that:
• I authorise the RBHS to use my personal information in accordance with the Privacy Policy.
• I have the authority to supply the personal information of the people listed on this claim form.
• The services listed on this claim are not claimable from other sources e.g. Medicare
Australia,workers compensation, third party or action for damages. If so, and the fund pays
benefits, I agree to reimburse the RBHS.
• I authorise any medical practitioner, health service provider or hospital to provide information
about anyone listed on this claim form, to enable this claim to be assessed.
• I certify that all information related to this claim is true and correct.
Reserve Bank Health Society Limited. A Registered Private Health Insurer. ABN 91 087 648 735. 0916 v1.0
Privacy Policy
The RBHS collects personal information for a number of purposes. The RBHS is committed to protecting
your personal information and complying with the requirements of the Privacy Act. Personal information is
primarily collected for the purpose of processing health benefit claims for members and dependants.
For more information about the RBHS Privacy Policy, please call 1800 027 299.
Member SignatureDate (ddmmyy)