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Mater Maternity Care contact details: Rocklands Road North Sydney NSW 2060 Telephone: (02) 9900 7690

Mater Maternity Care contact details:

Rocklands Road North Sydney NSW 2060 Telephone: (02) 9900 7690 Facsimile: (02) 9900 7680 Mater.MaternityBookings @svha.org.au www.materhospital.com.au

MATER MATERNITY BOOKING FORM

Please complete the following additional Health Fund details

and return form to Mater Maternity Bookings together with the:

Registration & Pre-admission details &

Privacy Collection Statement forms

Additional Health Fund information Patient details Contributor’s Name Level of cover NB: Patient Declaration

Additional Health Fund information

Patient

details

Contributor’s

Name

Level of cover

NB:

Patient

Declaration

Booking

Deposit details

of cover NB: Patient Declaration Booking Deposit details Surname: Single Family Given name: Overseas Cover No

Surname:

NB: Patient Declaration Booking Deposit details Surname: Single Family Given name: Overseas Cover No Cover Date
Single Family

Single

Single Family

Family

Booking Deposit details Surname: Single Family Given name: Overseas Cover No Cover Date of birth Couples
Booking Deposit details Surname: Single Family Given name: Overseas Cover No Cover Date of birth Couples

Given name:

Deposit details Surname: Single Family Given name: Overseas Cover No Cover Date of birth Couples ●
Overseas Cover No Cover

Overseas Cover

Overseas Cover No Cover

No Cover

Single Family Given name: Overseas Cover No Cover Date of birth Couples ● Single Membership DOES
Single Family Given name: Overseas Cover No Cover Date of birth Couples ● Single Membership DOES

Date of birth

Date of birth
Date of birth
Date of birth
Date of birth
Date of birth
Date of birth
Date of birth
Date of birth
Family Given name: Overseas Cover No Cover Date of birth Couples ● Single Membership DOES NOT
Couples

Couples

Given name: Overseas Cover No Cover Date of birth Couples ● Single Membership DOES NOT COVER

● Single Membership DOES NOT COVER charges you will incur if your baby requires treatment to the Neonatal Intensive Care Nursery. Please discuss with Maternity Bookings

● Self insured patients and patients with overseas cover are required to pay the estimated cost of hospitalisation two months PRIOR to confinement

I,

Admitting Officer Signature

MastercardVisa Card Number Cheque Cash Receipt Number

Visa

Mastercard Visa Card Number Cheque Cash Receipt Number

Card Number

ChequeMastercard Visa Card Number Cash Receipt Number

Cash

Mastercard Visa Card Number Cheque Cash Receipt Number
Mastercard Visa Card Number Cheque Cash Receipt Number
Mastercard Visa Card Number Cheque Cash Receipt Number

Receipt Number

I certify that the information shown on my Mater Booking Form and Health Fund information on the Registration & Pre-admission details are true & I agree to any medical information being given to my Health Fund in support of my claim. In consideration of the Mater Hospital Sydney agreeing to admit me as a patient to the Hospital

Sydney agreeing to admit me as a patient to the Hospital Credit Card 2 0 Date

Credit Card

2 0 Date
2
0
Date

Amex

Cardholder’s Name:

/

Expiry date

Received by:

Amex Cardholder’s Name: / Expiry date Received by: Amount Date:

Amount

Date:

Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Cardholder’s Signature 2 0
Cardholder’s Signature 2 0
Cardholder’s Signature 2 0
Cardholder’s Signature 2 0
Cardholder’s Signature 2 0
Cardholder’s Signature 2 0

Cardholder’s Signature

2 0

Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0
Amex Cardholder’s Name: / Expiry date Received by: Amount Date: Cardholder’s Signature 2 0

Name of Patient / Guardian (delete as required)

Hereby acknowledge to the St Vincent’s Private Hospitals Limited that I am personally liable for the payment of all fees and charges of whatsoever nature and kind incurred by me or on my behalf during my stay at the Mater Hospital Sydney, including but without limiting the generality there of the Delivery Suite fee, the daily bed fee, the theatre fee and the theatre extras, telephone/fascimile, charges for medications and physiotherapy or other specific treatments and I agree that I shall forthwith pay all such fees and charges to St Vincent’s Private Hospitals Limited upon demand whether orally or in writing being made therefore by St Vincent’s Private Hospitals LImited. I further agree that I shall be liable for all costs, expenses, legal and otherwise incurred by St Vincent’s Private Hospitals Limited in seeking to obtain payment of such fees and charges or in any way in connection therewith

Signature of Patient / Guardian (delete as required)

Revised Mater Hospital Sydney form_V2_March17_for Mater Maternity Bookings only (Re-order no. 018437)