Complete this form to request a rebate estimate.

Please confirm your full name as per your HIF membership card
Please confirm your HIF membership number as per your HIF membership card
Please confirm the best email address to contact you on
Please confirm the best telephone number to contact you on
Please attach a clear scan or photograph of your itemisied dental estimate. Illegible photographs will be rejected.
Please attach a clear scan or photograph of your itemisied dental estimate. Illegible photographs will be rejected.