Clearance Certificate Request

Your Cover

Payment

From

* Based on an Australian Government Rebate of %, % LHC loading, $ excess for a in . Please note that our prices will increase from 1 April

Change your cover or compare

If you are transferring from another health fund we will arrange for the transfer for you, by submitting this form, it gives us permission to contact your previous fund to obtain your cover details.

If you are transferring to an equivalent level of cover with equivalent benefits, you will not have to re-serve your waiting periods.

If you have cancelled your health insurance membership with another health fund, you will need to join UniHealth within 60 days to make sure you receive continuity of cover.

Benefits cannot be paid until your previous fund forwards a certificate of clearance to UniHealth and your membership has been paid to the date of service. If you and your partner are transferring from separate memberships, you will each need to complete a Clearance Certificate Request.

Please provide your existing fund details below

UniHealth member no.:

Previous fund name *

Previous membership number

Full name *

Date of birth *

Please provide information to UniHealth about *

Myself

My partner

My dependants

Date of existing fund termination *

By submitting this form, I hereby authorise UniHealth to terminate my membership from the above mentioned date with my existing fund and / or obtain details about my membership.* * indicates mandatory fields