You're buying GMHBA Health Insurance's 6 month prepaid Bronze Young Singles Package via PayPal!

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Title *
First Name *
Surname *
Gender *
Date of Birth *
Medicare Card Number *
Medicare Card Valid To*
Is your name on the Medicare Card the same as the name entered above? *
If you answered 'No' to the question above, please type your 1st name, second name and surname
Medicare Patient Reference Number (the no. next to your name on your Medicare Card) *
Home Address Line 1 *
Home Address Line 2
Suburb*
State*
Postcode*
Country (please enter Australia);*
AH /Home Phone (If no fixed line phone number put your mobile here)*
Mobile phone number
Email address (GMHBA will contact you via this email address!*
What date do you want your Bronze Young Singles Package cover to start?

Do you wish to receive the Federal Government 30% Rebate to get the $9.90 a week price?*
If you said 'Yes' to the Federal Government 30% rebate, are you eligible for Medicare?*
Do you have a previous health fund?*
If yes to the above, which health fund?
GMHBA Terms and Conditions of Service
Have you read and agreed to GMHBA's terms and conditions of service?*	Yes
Important Information
Have you read the Important Information? Remember, no benefits are payable for: eye surgery, gastric banding, joint replacement, renal dialysis obstetrics and IVF and related services.*	Yes
Privacy Policy
Have you read and agreed to GMHBA's privacy policy?*	Yes
Is the information you entered in this form true and correct?*	Yes
Hi and thanks for getting to the bottom of the form! You'll get a confirmation email from me shortly. So please make sure your email address is correct above. After you submit this form you'll goto PayPal to complete your prepaid Bronze Young Singles Package purchase. Thank you. Jonathan Crabtree, e-Community Manager.