Thanks for applying to join ACA Health. Before you begin this process, please make sure you have these documents handy:

• Proof of eligibility (e.g. Company ID card or payslip)
• Proof of age (e.g. Driver’s Licence or Birth Certificate for all adults on the policy)
• Bank account details (for direct credit)
• Credit card details (for direct debit if applicable)

• Confirming eligibility*
  • Current employee of an Adventist Church company
  • Past employee of an Adventist Church company
  • Relative of eligible person
  • Past member
  • Local Church Officer
  Past and present employees of incorporated Adventist organizations are eligible to join including their partners/spouses, dependents, siblings, parents and grandparents are also welcome. Most Adventist organizations were incorporated between 2000 and 2004. If you were employed before 2000 you may not be able to join ACA-Health. If in doubt please feel free to contact ACA-Health on 1300 368 390.
• Relative of elIgibile person*
  Please choosePartnerSiblingChildParentGrandchildDependant of SiblingOther

Local Church Officer

• Local Church Officer*
  Please chooseElderDeacon and DeaconessClerkTreasurerDepartment and Organisation LeaderChildren's Ministries Coordinator and CommitteeCommunication SecretaryFamily ministries Coordinator and CommitteeHealth Ministries Coordinator and CommitteeMusic CoordinatorsReligious Liberty LeaderSabbath School Superintendent and otherBible School CoordinatorAdventist Community Services Leader or DocasStewardship Ministries LeaderPathfinder Club Directors, Director and Counselors
• Location held (Church)*
• Year position held*

Current employee of an Adventist Church company

• Select Company Name*
  Please chooseSouth Pacific DivisionACA Health Benefits FundSouth Pacific Division - SustentationSydney Adventist HospitalSanitarium Health FoodsOtherAdventist Media Network/SignsAvondale CollegeAustralian Union ConferenceGreater Sydney - ConferenceGreater Sydney - SchoolsGreater Sydney - Adventist Retirement VillageNorth NSW - ConferenceNorth NSW - SchoolsNorth NSW - Adventist Retirement VillageSouth NSW - ConferenceSouth NSW - SchoolsSouth Australian - ConferenceSouth Australian - SchoolsSouth Australian - Adventist Retirement VillageNorth Australian - ConferenceNorth Australian - SchoolsTasmanian - ConferenceTasmanian - SchoolsVictorian - ConferenceVictorian - SchoolsVictorian - Adventist Retirement VillageWestern Australian - ConferenceWestern Australian - SchoolsWestern Australian - Adventist Retirement VillageSydney Adventist Hospital FoundationAvondale College FoundationKaralundi Aboriginal Education CentreMirriwinni Gardens Aboriginal CentreSouth Queensland - ConferenceSouth Queensland - SchoolsAdventist Development and Relief AgencySouth Queensland - Adventist Retirement VillageTransferring Employee
• Please attach proof of employment (e.g. ID card, payslip)*
  Drop files here or Select files

  Max. file size: 3 MB, Max. files: 2.

Past employee of an Adventist Church company

• Select Company Name*
  Please chooseSouth Pacific DivisionACA Health Benefits FundSouth Pacific Division - SustentationSydney Adventist HospitalSanitarium Health FoodsOtherAdventist Media Network/SignsAvondale CollegeAustralian Union ConferenceGreater Sydney - ConferenceGreater Sydney - SchoolsGreater Sydney - Adventist Retirement VillageNorth NSW - ConferenceNorth NSW - SchoolsNorth NSW - Adventist Retirement VillageSouth NSW - ConferenceSouth NSW - SchoolsSouth Australian - ConferenceSouth Australian - SchoolsSouth Australian - Adventist Retirement VillageNorth Australian - ConferenceNorth Australian - SchoolsTasmanian - ConferenceTasmanian - SchoolsVictorian - ConferenceVictorian - SchoolsVictorian - Adventist Retirement VillageWestern Australian - ConferenceWestern Australian - SchoolsWestern Australian - Adventist Retirement VillageSydney Adventist Hospital FoundationAvondale College FoundationKaralundi Aboriginal Education CentreMirriwinni Gardens Aboriginal CentreSouth Queensland - ConferenceSouth Queensland - SchoolsAdventist Development and Relief Agency
• Please attach proof of employment (e.g. ID card, payslip)*
  Drop files here or Select files

  Max. file size: 3 MB, Max. files: 2.

Relative of eligible person

• Eligible persons full name*
• Eligible persons phone number*
• Eligible persons membership number
• Employment or Local Church Officer*
  • Employment
  • Local Church Officer
• Select Company Name*
  Please chooseAdventist Retirement villagesAdventist Development and Relief AgencySigns Publishing CompanySanitarium Health and wellbeing companyAvondale College FoundationSydney Adventist Hospital FoundationKaralundi Aboriginal Education CentreMirriwinni Gardens Aboriginal CentreOr any other incorporated entity that is affiliated with the Seventh-Day Adventist Church
• Please attach proof of employment (e.g. ID card, payslip)
  Drop files here or Select files

  Max. file size: 3 MB, Max. files: 2.
• Local Church Officer*
  Please chooseEldersDeacons and DeaconessesClerkTreasurerDepartment and Organisation LeadersChildren’s Ministries Coordinator and Committee MembersCommunication SecretaryFamily Ministries Coordinator and Committee MembersHealth Ministries Leader and Council MembersMusic CoordinatorsReligious Liberty LeaderSabbath School Superintendent and Other Sabbath School OfficersBible School CoordinatorAdventist Community Services Leader or Dorcas Society LeaderStewardship Ministries LeaderPathfinder Club Directors, Deputy Directors and Counselors / Instructors
• Location held (Church)*
• Year position held*

Past or transferring member or Dependant

• Membership name*
• Membership number*

Local Church Officer

• Declaration*
  • I hereby declare that I have been elected by the SDA Church to serve in the official capacity of Please choose. My most recent year of service in this position is/was .

Relative of eligible person

• Declaration*
  • I hereby declare that I am the Please choose of . They were elected by the SDA Church to serve in the official capacity of Please choose. The most recent year of their service in this position is/was .

• Hospital*
  • Deluxe
  • Private
  • Bronze Essentials
  • Basic
  • None
• Extras*
  • Complete
  • Lite
  • None
• Membership type*
  • Single
  • Couple
  • Family
  • Single Parent
• Dependant Extension
  • Yes
  • No

  "Dependant" means and includes:
  (a) A Policy Holder’s spouse or de facto partner;
  (b) A Policy Holder’s children under twenty-one (21) years of age who do not have a spouse or de facto partner;
  (c) "Student Dependants" - A child of the Policy Holder who;
  (i) does not have a spouse or de facto partner;
  (ii) is a full-time student at a school, college or university;
  (iii) is twenty-one (21) years or over and under the age of twenty-five (25) years;
  (iv) is not earning more than $20,000 gross per annum; and
  (v) has been accepted by the Fund as a "student dependant."
  (A statement in respect of Student Dependants must be provided each year by the Policy Holder).
  (d) “Dependent Child Non-Student” - A child of the Policy Holder who;
  (i) does not have a spouse or de facto partner;
  (ii) is twenty-one (21) years or over and under the age of twenty-five (25) years; and
  (iii) is not receiving full‑time education at a school, college or university.
  A Dependent Child Non-Student may only be covered as a dependant on an “extended family policy”.
  (e) Such other persons approved by the Board of Directors as being dependants.

• Please start my membership & pay the appropriate contributions from:*
  DD slash MM slash YYYY

• Title
  MrMrsMissMs
• Surname*
• Given name*
• Middle name
• Street address*
• Suburb*
• Postcode*
• State*
  ACTNSWNTQLDSATASVICWA
• Home phone number
• Mobile/other phone number*

• Date of birth*
  DD slash MM slash YYYY
• Gender*
  m/fMaleFemale
• Email Address*

• Please attach proof of age (e.g. Driver’s license, birth certificate or passport)*
  Drop files here or Select files

  Max. file size: 3 MB, Max. files: 2.

• *

  Relation to member*	Surname*	Given names*	Date of birth*	Gender*	Email address*	Mailing address*	Phone number*	Authorise*
  RelationshipSpousePartnerSonDaughterStep DaughterStep Son				m/fMaleFemale				YesNo

• Authorise - for each person that has 'Yes' selected in this field, the applicant (policy holder) gives permission for that person to have equal authority when dealing with the membership. I understand that this means he/she can claim benefits on my behalf, ask questions about the membership, and make changes to the policy. I understand that this arrangement will continue until I inform ACA Health Benefits Fund in writing that this arrangement is to cease.

• Please attach proof of age for people over age 21 (e.g. Driver’s license, birth certificate or passport)
  Drop files here or Select files

  Max. file size: 3 MB, Max. files: 2.

• Do you wish to apply for Australian Government Rebate on Private Health Insurance?*
  • Yes
  • No

  Families and individuals who pay private health insurance premiums may be eligible for Australian Government rebates.

  Your costs may be reduced if you have a health insurance policy with an Australian registered health insurer that provides the following cover:
  Hospital
  General and extras, or
  Both
  

  The rebate reduces the amount you pay for private health insurance. The rebate amount you get is based on the age of the oldest person covered by the policy and by annual earnings.

  You must be covered by the policy and be eligible for Medicare to receive the rebate. For more information, you can go to https://www.humanservices.gov.au

• How would you like to apply?
  • Download PDF form and upload
  • Complete an online form

• You can download the form here and upload it in this page.

  Alternatively, you can fill the online form below.

• Upload your completed Medicare Rebate form*
  Drop files here or Select files

  Max. file size: 3 MB, Max. files: 2.

• Application to receive the Australian Government Rebate on Private Health Insurance as a reduced premium

  Important Information

  • Complete this form and lodge it with your Health Fund to receive the Australian Government Rebate on Private Health Insurance 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.
  • Policy holders must nominate the level of rebate they believe they are entitled to.
  
  

  *Income thresholds increase by $1500 for every child after the first.

  • If a policy holder claims a rebate level above their actual entitlement a recovery of monies will occur through the Australian Taxation Office (ATO) as a tax debt.
  • If a policy holder claims a rebate level below their actual entitlement a refund will occur through the ATO as a tax credit.
  • If at any stage you wish to stop receiving or wish to nominate a new income tier for the Australian Government Rebate on Private Health Insurance as a reduced premium, you must notify your Health Fund as soon as possible.
  
  

  Assistance

  For more information about the Australian Government Rebate on Private Health Insurance, go to privatehealth.gov.au

  Questions about Medicare eligibility can be made at any Human Services' Service Centre or by calling 132 011.

  Note: Call charges apply – calls from mobile phones may be charged at a higher rate.

  
  

  Claimant’s details

  Name of Private Health Fund: ACA Health

• Membership Number#
• Note: If the membership number is unknown leave field blank
  
  
• Are you covered by the policy?*
  • Yes
  • No

• Applicants not covered by the policy cannot claim the Australian Government Rebate on Private Health Insurance (excluding child only policies) and employers and trustees of organisations cannot claim the Australian Government Rebate on Private Health Insurance on policies paid on behalf of employees.

• Date premium reduction to commence*
• Medicare Card Number*
• Medicare Card Valid Until*
• Your full name as it appears on your Medicare Card
• Surname*
• Given Names*
• Address*
• Suburb*
• Postcode*
• State*
• Daytime Phone Number*
• Date Of Birth*
• • Postal Address (if different to above)
• Address*
• Suburb*
• Postcode*
• State*
• Nominate your level of rebate*
  • Base Tier
  • Tier 1
  • Tier 2
  • Tier 3
• Gender
  • Male
  • Female

• Details of People Covered by Policy

• Note: Provide details of all people covered by the policy (do not include yourself).

  Family Name	Given Names	Date of Birth	Gender	Dependant Child (Y/N)

• All people listed on the policy must be eligible to claim Medicare for you to receive the rebate as a reduced premium.

  If you are unsure whether you are eligible for Medicare, go to https://www.humanservices.gov.au/customer/services/medicare/medicare-card for more information.

• Are all the people on the policy listed on a Medicare card or entitled to a Medicare card?*
  • Yes
  • No
• Declaration*
  • I declare that the information I have provided in this form is complete and correct. I understand that giving false or misleading information is a serious offence.
• Signature*
  • Please check this box to indicate you have read and understood the declaration.
• Date: 10/08/2022

• Are you transferring from another health fund?*
  • Yes
  • No

  Lifetime Health Cover and Loadings

  Persons taking hospital policies pay 2% more for each year they are over 30 years old, to a maximum of 70% and for a maximum of 10 years. Ancillary only policies are not affected.

  Persons born on or before 1 July, 1934 will not have to pay more. All existing members as at 1/7/2000 were credited with a certified age of 30 and will attract the base rate premium for as long as they maintain their hospital policy.

  Please refer to the Department of Health website www.health.gov.au for full details of minimum period of membership, periods of absence, periods of suspension, special provisions for refugees and Australians overseas and LHC loading removal.

• You may be subject to LHC Loading which will alter your policy’s cost

• Name of previous Fund*
• Membership number*

• Transfer certificate on my behalf*
  • Please request a transfer certificate on my behalf to be sent to ACA Health.

• Name of Financial Institution*
• Account Name*

• Direct Credit - BSB*
• Direct Credit - Account Number*

• I agree to ACA Health’s terms and conditions*
  • I agree to ACA Health's terms and conditions

• How would you like to pay?*
  • Direct Debit
  • Self Managed
  Direct Debit: Monthly charged by ACA usually on the 20th of the month.
  Self-Managed: Members are required to make regular payments prior to their next payment coming due using the below options
• Self Managed
  • Website Payments
  • Phone Payments
  • BPAY

• • Use previous bank details

• Name of Financial Institution
• Account Name

• Direct Debit - BSB*
• Direct Debit - Account Number*

• Where did you hear about us?
  • Family/Friend
  • HR/Payroll Office/Employer
  • Past Member or Dependant
  • Sales Representative
  • Shop and Share
  • The Record
  • Website
  • Other
• 
  
• ACA Health’s Terms and Conditions*
  • I have read and understood ACA Health’s Terms and Conditions
• ACA Health’s Privacy Statement*
  • I confirm that I am the registered policyholder for this account, I have read and agree to ACA Health's Privacy Collection Statement and Privacy Policy
• I declare all information provided in this form to be accurate and true*
  • I declare all information provided in this form to be accurate and true