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Preamium
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Health Insurance Referral Form

Health Insurance Referral

General Insurance Application
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone Number*
(including country code)
Insurance (Health)
Partners Date of Birth
DD slash MM slash YYYY
Hospital Coverage Level
Extras Cover Level
Income
Excess
What is important to the client?
- Public hospital accommodation
- Private hospital accommodation
- Shared room
- Single room in a private hospital (where available)
- Accidental injury
- Appendicitis
- Cardiac treatments
- Cancel treatment
- Intensive and coronary care
- Joint reconstructions and investigations
- Medical gap cover
- Gynecological procedures
- Neurostimulators
- Operating theatre
- Psychiatric services
- Rehabilitation services
- Removal of tonsils and adenoids
- Spinal Surgery
- Surgical implanted prostheses
- Cataract and corneal transplants
- Dental implant surgery
- Joint replacements including hips and knees
- Pregnancy related services (including childbirth)
- IVF and assisted reproductive services
- Healthy Start benefit (pregnancy related services)
- Gastric banding and all obesity surgeries
- Haemodialysis
- Insulin Pumps
- Hospital in the Home
- Rehabilitation in the Home
- New Family program
- Podiatric surgery
- Palliative care
- Cochlear implants
- Plastic & Reconstructive Surgery
- Blood (harvesting of bone marrow for transplantation)
- Dental
- Optical
- Chiropractic and Osteopathy
- Physiotherapy and Hydrotherapy
- Myotherapy
- Acupuncture
- Naturopathy
- Orthodontics
- Remedial Massage
- Homeopathy
- Ambulance Subscription
- Ambulance Transport
- Exercise Physiology
- Psychology
- Counselling
- Pharmacy
- Travel Vaccinations
- Dietetics
- Audiology
- Antenatal and postnatal classes
- Eye therapy
- Speech therapy
- Occupational Therapy
- Podiatry
- Nursing
- Prostheses (non-surgical)
- Blood glucose monitor
- Extremity pump
- Nebuliser pump
- Sleep apnoea monitor
- Tens monitor
- Hearing aids
- Orthopaedic repairs
- Orthotic appliances (foot)
- Orthopaedic appliances
- Pressure garments
- Weight Management Program
- Fluoride dietary supplement
- Swimming lessons
- Flu Vaccination
- Cancer Council Australia UV Products
- Melanoma Surveillance Photography
- Nicotine replacement patches
- HPV Vaccination
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