Download forms

Please find below links to forms that you may need – an application form, claim forms, the Government Rebate form, a Clearance Request form, Letter of Authority, Authority of Release and more.

If you have trouble downloading any of the forms linked to from this page please refer to our download help page.

Download help

Confidentiality form

Application form

Claim form

Overseas visitors claim form

Particulars of Ambulance Transportation form

Direct debit form

Government Rebate form

Clearance Request form

Letter of Authority form

Authority of Release of member's information form

Confidentiality form

Whether you like to keep things private or would rather share, it's important that you're comfortable with who sees your health claim information. Whichever group you fall into, we give you a choice to suit your needs.

Please complete and return this form ensuring all people on your membership except those under 17 have indicated their preferred option.

Download a confidentiality form

Application form

If you'd like to join Mutual Community, you can download and complete this form then post it to us, or join online. In order to complete either form you will need to:

Know which cover(s) you would like
Know the details of all persons you would like to cover
Be able to name the fund you are transferring from (if applicable)

Download an application form

Join online

Claim form

You can claim by mail or online.

To claim by mail, download and print out a claim form, complete it, attach the original account(s) you received from your health care provider - and the original receipt(s) if you paid your provider - and post to:

Mutual Community
Customer Claims
GPO Box 770
Northern Territory 0801

If you are an overseas visitor, please use the overseas visitors claim form.

If you are making an Emergency Ambulance claim, please also complete and attach the Particulars of Ambulance Transportation (PAT) form.

Download a claim form

Download an overseas visitors claim form

Claim online

Particulars of Ambulance Transportation form

Emergency Ambulance claims need to be supported with a completed Particulars of Ambulance Transportation (PAT) form.

Download a Particulars of Ambulance Transportation form

Claim queries

Please remember that claims can only be paid within 2 years of the date on which the service was rendered.

If you have a question about:

The status of your claim
How to fill in a claim form
What documents you need to attach to your claim form

Please do not hesitate to contact us.

Direct debit form

Pay by direct debit from a credit card, cheque or savings account and keep your health insurance payments up-to-date automatically. Simply complete and return the direct debit authority form or use our online payment form for your convenience.

Download a direct debit authority form

Pay online

Government Rebate form

Complete and return this form to receive the Federal Government Rebate as a reduced premium. All the people listed on the policy must be eligible to claim Medicare for you to receive the rebate as a reduced premium.

If at any stage you wish to stop receiving the Federal Government Rebate as a reduced premium please notify us as soon as possible.

Download a Government Rebate application form

Clearance Request form

Complete and return this form if you are transferring from another fund and Mutual Community will cancel your existing health fund membership for you.

Your previous fund will subsequently forward a Clearance Certificate to us that will confirm your previous cover details so we are able to apply all appropriate waiting period waivers on your new membership, determine your Federal Government Rebate and identify your Lifetime Health Cover status - including your Lifetime Health Cover Age, any applicable loadings and accumulated days without hospital cover.

If your previous fund sends you the Clearance Certificate directly, please forward it to Mutual Community for processing.

Please note that you must personally advise your bank to cancel any direct debit arrangement with your existing health fund.

Download a Clearance Request form

Letter of Authority form

This letter authorises another person to be given the same level of access as you have to your membership.

Download a Letter of Authority form

Authority of Release of member's information form

This form enables you to authorise a provider to disclose your treatment and/or billing records to Mutual Community for the purpose of verifying services provided to you - Mutual Community will only use this information in accordance with the Privacy Act and National Privacy Principles.

Authority of Release of member's information form