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.

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Complete this form to request a rebate estimate.

Your full name*

Please confirm your full name as per your HIF membership card

HIF member number*

Your email address*

Your date of birth

Your Phone Number*

Please confirm the best telephone number to contact you on

Full name of patient*

Hospital name*

Hospital suburb and state*

For example: Perth, WA

Anticipated date of admission*

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

Doctor's name*

E.g. Dr John Smith

Doctor's provider number*

E.g. 0000XZ. This is your provider's Medicare number. If you don't know your doctor's provider number, please contact them direct.

Doctor's item number(s) and charge(s)

Please complete all that apply (e.g. "Item no: 123" & "Charge: $100")

Additional comments

Please enter any other information you feel is relevant to this section

If you already have a written estimate from your doctor, please attach a copy here

Please attach a scan or photo

Anaesthetist (if applicable)

Anaesthetist name

Anaesthetist provider number

Item number & charge

Please complete all that apply.

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

Assisting specialist's name

Assisting specialist's provider number

If you already have a written estimate from the assisting specialist, please attach a copy here

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.

Prosthesis item number

Prosthesis charge

Additional comments regarding prosthesis

How would you like to be advised of your estimate?*

Email me

Phone me

Data Collection

By clicking Submit I consent to the collection of my data in accordance with HIF’s Privacy Policy.

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