Hospital & Medical Estimate Request Form.

Before receiving any hospital treatment we recommend that you complete the form below or call us on 1300 13 40 60 for a rebate estimate so you know exactly what your gap, if any, might be.

HIF PRIVATE HOSPITAL COVER OPTIONS

Complete this form to request a detailed rebate estimate prior to undergoing treatment.

Please confirm your full name as per your HIF membership card
Please confirm the best telephone number to contact you on
For example: Perth, WA

Doctor/Specialist/Surgeon who will be providing or supervising your procedure or treatment.

E.g. Dr John Smith
E.g. 0000XZ. This is your provider's Medicare number. If you don't know your doctor's provider number, please contact them direct.
Please complete all that apply (e.g. "Item no: 123" & "Charge: $100")
Please enter any other information you feel is relevant to this section
Please attach a scan or photo

Anaesthetist (if applicable)

Please complete all that apply.

Assisting Doctor / Specialist / Surgeon who may be assisting with provision of your procedure or treatment (if applicable)

Please attach a scan or photo

Prosthesis details (if applicable)

Your treating doctor will be able to advise you of these items if required for your procedure.