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Bupa Australia Pty Ltd

ABN 81 000 057 590


X Nominate an authorised person on my membership X Change details of an existing authorised person on my membership
I, as the Policyholder, give the authorised person the same rights to operate the membership as I have.
I acknowledge that the authorised person will have the same rights and obligations as I have, including access to health information, however only I can cancel or remove
myself from the membership.
I acknowledge that on Overseas Visitors covers, the authorised person will have the same rights and obligations as I have, including the ability to cancel or remove myself
from the membership.
Authorisation is given at my own risk and I accept I have no recourse against the fund for any acts or omissions made by the authorised person.
I acknowledge that this authority will remain active on my membership until I contact the fund and request that it be revoked.
I confrm that I must comply with and be bound by the Policy Terms & Conditions, Fund Rules or Overseas Visitors Rules and that I will remain fully responsible for the
membership and the actions of the authorised person.
Policyholders signature Date
D D M M Y Y
Bupa membership number
Surname
First name
Initial Title Date of birth
D D M M Y Y X Male X Female
Postal address (if different from home address)
Postcode
Home phone number (including area code)
Mobile phone number
Fax number
Email address
AuTHORI Ty FORm
1. Please complete this form USING BLACK INK and write within the boxes in CAPITAL LETTERS.
Mark appropriate answer boxes with a CROSS. Start at the left of each answer space and leave
a gap between words. PLEASE DO NOT STAPLE.
2. Read the declaration and sign all the signature panels required.
SECTION A: Im applying to
SECTION C: Policyholders declaration
SECTION B: Your details
Home address
Postcode
10242-10-11S 1/2
X
Check that you have signed all the signature boxes relevant
to your application, including the declaration above.
PLEASE DO NOT STAPLE.
Please mail your application (no postage stamp required) to:
Bupa Reply Paid 9809 BRISBANE QLD 4001

If you would like any assistance, please call us on 134 135.
Bupa Australia Pty Ltd ABN 81 000 057 590
OFFICE USE ONLY
Document name
Consultant
Session ID
The information collected on this form will be primarily used for the purposes of recording the authority on your membership, verifying the identity of the authorised person
and for related administrative purposes. The policyholder and the authorised person have a right to request reasonable access to the information that the fund holds about
them. To view our Information Handling policy please visit our website, bupa.com.au.
To be completed by the authorised person
I, the authorised person, accept the rights and obligations conferred by this authority. I confrm I am over the age of 18 years and have the capacity to assume the rights
and obligations conferred by this authority. I acknowledge that with the exception of Overseas Visitors covers, only the policyholder retains the right to cancel the
membership or remove themselves from the membership.
Authorised persons signature Date
D D M M Y Y
Surname
First name
Initial Title Date of birth
D D M M Y Y X Male X Female
Home address
Postcode
Postal address (if different from home address)
Postcode
Home phone number (including area code)
Mobile phone number
Fax number
Email address
My relationship to the policyholder is
SECTION D: Authorised persons details
SECTION E: Authorised persons declaration
PRIVACY NOTE
Just before you send
10242-10-11S 2/2