Complete this form to request a benefit estimate.

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 number. If you don't know your doctor's provider number, please contact them direct.
Please complete all that apply (e.g. "Item no: 00123" & "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.

Data Collection

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