Contact Form

Name *

Phone *

Email Address *

Date of Birth *

Location *

The policy type you are interested in *

Hospital CoverExtras CoverCombined Hospital and Extras Cover

Policy is for *

A Single PersonA Single ParentA Family

Which Medicare Card do you hold? *

Standard Medicare Card (Green)Interim Medicare Card (Blue)Reciprocal Medicare Card (Yellow)No Medicare Card

How did you hear about Mildura Health Fund? *

Do you currently have Private Health Insurance? *

Current Health Fund *

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How many years have you held private health insurance? *

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