Direct Debit Form

1300 653 099
gmfhealth.com.au
PO Box 513 Kalgoorlie WA 6433
Direct Debit Form
1. Member Details
Membership Number
Title
Given Name(s)
SurnameEmail
Residential Address
State
Postcode
Postal Address
State
Postcode
2. Payment Frequency
Please indicate one of the following payment options
Fortnightly
Monthly
Quarterly
Half Yearly
Yearly
If you selected fortnightly or monthly payment frequency please nominate what date between days 1 and 28 days you would like deductions to
commence
/
/
Please note that your initial deduction may include an adjustment to ensure your membership is financial or to coincide with your nominated date.
3. Direct Debit Request
The Schedule - Details of account to be debited.
Name of Financial Institution
sdas
Branch
Account in the name of
NB: Direct Debit is not available from all accounts, please check with your bank/financial institution.
Account Details
Cheque
Savings
BSB / Financial Institution Number
–
Account Number
Please ensure account details are correct and that this request is signed by the required number of authorised signatories.
SignatureDate
SignatureDate
Want to pay by Credit Card?
If you would like to pay your premium from your credit card account, please call us on 1300 653 099 to arrange.
Ensuring your Privacy
HBF Health Limited ABN 11 126 884 786 trading as GMF Health (GMF) complies with the Privacy Act 1988 (Cth) to ensure that your personal (including sensitive) information (Information)
is protected. GMF will use the information collected to process payment of your health insurance premium. We may not be able to perform this function or only perform it to a limited
extent if you do not provide us with your Information. We may disclose your personal information to financial institutions or your employer. GMF collects, uses and discloses your
Information in accordance and our Privacy Policy which is available at gmfhealth.com. au or by contacting a GMF Health Member Service Consultant on 1300 653 099. Our Privacy
Policy contains further information about how GMF handles your Information. This includes information on how you can access and\or seek the correction of your Information that we
hold about you as required by law and how to make a complaint about the way your Information is being handled by GMF and how GMF will deal with your complaint.
If you have any questions about how GMF handles your Information, please contact our privacy officer by writing to GPO Box C101, Perth, Western Australia, 6839.
PLEASE DETACH AND RETAIN THIS SECTION FOR YOUR RECORDS
Direct Debit Service Agreement
1. HBF Health Limited ABN 11 126 884 786 trading as GMF Health (GMF) User ID: – 159206 (Debit User) will initiate direct debit payments in the manner referred to in the Schedule.
2. Debit payments will be made when due. GMF will not issue individual confirmation of payments made. 3. Please confirm that GMF do send the confirmation. The first deduction
may be for more or less than the regular payment amount to ensure membership is financial. The date and amount of the initial deduction will be agreed on by GMF and the
member at the time the direct debit arrangements are set up. GMF will send written confirmation of the first deduction amount within 14 days of direct debit payments being set
up. 4. GMF will give the member at least 14 days written notice if GMF proposes to vary details of this arrangement, including the amount and frequency of payments. 5. If the
member wishes to defer any payment or alter any of the details referred to in the Schedule, the member must either telephone GMF on 1300 653 099 or write to GMF at PO Box
513, Kalgoorlie WA 6433. 6. Any queries concerning disputed debit payments must be directed to GMF Health in the first instance. Members may obtain details of the direct debit
process by contacting GMF on 1300 653 099 or write to GMF at PO Box 513, Kalgoorlie WA 6433. 7. Direct debiting is not available on the full range of accounts at all financial
institutions. If in doubt, the member should check with their financial institution at which the account is held. 8. The member should ensure that the account details given in the
Schedule are correct by checking them against a recent statement from the financial institution at which the account is held. 9. By signing the Direct Debit Authority, the member
warrants and represents that he/she/they is/are duly authorised to request the debiting of payments from the account described in the Schedule. 10. It is the member’s
responsibility to have sufficient funds available in the account to be debited to enable debit payments to be made in accordance with their Direct Debit Authority. 11. If a debit
payment falls due on any day which is not a business day, the payment will be made on the next business day. 12. If a debit payment is returned unpaid, the member may be
charged a fee for each unpaid item. 13. Members wishing to cancel their Direct Debit Request or to stop individual payments must contact GMF by telephoning 1300 653 099 or
by writing to GMF at PO Box 513 Kalgoorlie WA 6433 before the day their payment is due to be debited. 14. Except to the extent that disclosure is necessary in order to process
debit payments, investigate and resolve disputed transactions or is otherwise required by law, GMF will keep details of the member’s account and debit payments confidential.
HBF Health Limited ABN 11 126 884 786
GMF-017 24/11/2015