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    Authority Form

    Uploaded by

    rosegr332
    This document contains an authority form for nominating an authorized person or organization on a Bupa health insurance membership or changing details of an existing authorized person. The form requests information such as the applicant's name, address, membership number, and contact details. It also contains sections for the applicant's declaration authorizing access and a signature, as well as sections to provide details and declaration of the authorized person or organization. Instructions are provided to complete the form in black ink and capital letters, and to return it without stapling.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Authority Form

    Uploaded by

    rosegr332
    51 views2 pages
    This document contains an authority form for nominating an authorized person or organization on a Bupa health insurance membership or changing details of an existing authorized person. The form requests information such as the applicant's name, address, membership number, and contact details. It also contains sections for the applicant's declaration authorizing access and a signature, as well as sections to provide details and declaration of the authorized person or organization. Instructions are provided to complete the form in black ink and capital letters, and to return it without stapling.

    Original Description:

    Bupa Authority form

    Original Title

    Authority form

    Copyright

    © © All Rights Reserved

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    This document contains an authority form for nominating an authorized person or organization on a Bupa health insurance membership or changing details of an existing authorized person. The form requests information such as the applicant's name, address, membership number, and contact details. It also contains sections for the applicant's declaration authorizing access and a signature, as well as sections to provide details and declaration of the authorized person or organization. Instructions are provided to complete the form in black ink and capital letters, and to return it without stapling.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    51 views2 pages

    Authority Form

    Uploaded by

    rosegr332
    This document contains an authority form for nominating an authorized person or organization on a Bupa health insurance membership or changing details of an existing authorized person. The form requests information such as the applicant's name, address, membership number, and contact details. It also contains sections for the applicant's declaration authorizing access and a signature, as well as sections to provide details and declaration of the authorized person or organization. Instructions are provided to complete the form in black ink and capital letters, and to return it without stapling.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Authority Form

    1. Please complete this form USING BLACK INK and write within the boxes in CAPITAL LETTERS.
    Mark appropriate answer boxes with a CROSS. Start at the left of each answer space and leave
    a gap between words. PLEASE DO NOT STAPLE.
    2. Read the declaration and sign all the signature panels required.

    SECTION A: I’m applying to


    Nominate an authorised person/organisation on
    X my membership X Change details of an existing authorised person on my membership

    SECTION B: Your details


    Bupa membership number Mail address (if different from residential address)

    Surname

    Postcode
    First name Home phone (including area code)

    Initial Title Date of birth Sex (M/F) Work phone (including area code)
    D D M M Y Y X
    Residential address Mobile

    Email

    Postcode

    SECTION C: Policyholder’s declaration


    I, as the Policyholder, give the authorised person or authorised organisation the same rights to the membership as I have, subject to:
    • O
     nly I have the ability to cancel or remove myself from the membership, unless I am on Overseas Visitors cover in which case the authorised
    person or authorised organisation may cancel or remove me from the membership.
    • An authorised person may access my health information, however, an authorised organisation cannot access my health information.
    Authorisation is given at my own risk and I accept I have no recourse against the fund for any acts or omissions made by the authorised person
    or authorised organisation. This authority will remain active on my membership until I contact the fund and request that it be revoked.
    I declare that: my typed name stands as my signature for the purposes of this form.

    Applicant’s signature Date

    D D M M Y Y Y Y
    102421217S

    10242-08-21 1/2

    Bupa HI Pty Ltd


    ABN 81 000 057 590
    SECTION D: Authorised person’s/organisation’s details
    Authorised person’s details Mobile
    If you would like to authorise a person, please fill in this section.

    Surname Email

    First name My relationship to the policyholder is

    Initial Title Date of birth Sex (M/F)


    Authorised organisation’s details
    D D M M Y Y X If you would like to authorise an organisation, please fill in this section.
    Residential address
    Organisation’s name

    ABN (if applicable)


    Postcode

    Mail address (if different from residential address)


    ORGX (organisation identification number)

    Contact surname
    Postcode

    Home number (including area code) Contact first name

    Work phone (including area code) My relationship to the policyholder is

    SECTION E: Authorised person’s/organisation’s declaration


    To be completed by the authorised person/organisation
    I, the authorised person, accept the rights and obligations conferred by this authority. If I am being authorised in my individual capacity, then
    I confirm I am over the age of 18 years and have the capacity to assume the rights and obligations conferred by this authority. If I am accepting
    this authority on behalf of an organisation, then I warrant that I am authorised and have the capacity to assume the rights and obligations
    conferred by this authority on the organisation. I acknowledge that with the exception of Overseas Visitors covers, only the policyholder
    retains the rights to cancel the membership or remove themselves from the membership.
    I declare that: my typed name stands as my signature for the purposes of this form.

    Signature Date

    D D M M Y Y Y Y

    PRIVACY NOTE
    The information collected on this form will be primarily used for the purposes of recording the authority on your membership, verifying the
    identity of the authorised person or authorised organisation and for related administrative purposes. The policyholder and the authorised
    person have the right to request reasonable access to the information that the fund holds about them. To view our Information Handling policy
    please visit our website, bupa.com.au.

    Just before you send


    Check that you have signed all the signature boxes relevant
    OFFICE USE ONLY
    X to your application, including the declaration above.
    102421217S

    Document Name
    PLEASE DO NOT STAPLE.
    Please mail your form to: 
    Bupa Health Insurance GPO Box 2213 BRISBANE QLD 4001 Consultant

    Alternatively, you can drop by a Bupa Health Insurance store. 


    If you would like any assistance, please call us on 134 135. Session ID
    Bupa HI Pty Ltd ABN 81 000 057 590 

    10242-08-21 2/2

    Bupa HI Pty Ltd


    ABN 81 000 057 590

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