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Claim Form - Medibank

1. Member InformationMembership Number: _____Title: _____ First Name: _____ Surname: _____Date of Birth: ____ / _____ / _____Preferred day time contact number: _____ I agree to be contacted by phone regarding any additional information required with this Claim . I hold an Overseas Student, Visitor or Working Visa Claim Information Please note, Medibank will only pay benefits for claims lodged within two (2) years of the date of service and your membership must be current at date of service. Payments will be made by your preferred method (EFT / Chq) and a statement of benefit (not available for OSHC members) will be sent to the address we have on record.

Members’ Choice provider, make changes to your details and even make a claim. Find out more about My Medibank, visit medibank.com.au/members For OSHC members visit medibankoshc.com.au We’re here to help Call us on 132 331 or visit one of our Medibank stores for help with completing this claim form or any general enquiries.

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