Branch 400 LMF Application

Local Medical Fund Application Form (Branch 400)

Member request for consideration of assistance towards costs of GP visits.

This field is for validation purposes and should be left unchanged.
DD slash MM slash YYYY
Name(Required)
Please enter a number from 400001 to 400999.
Hibernians membership number, beginning with 400.
Address
Consent(Required)

Medical invoices

Please attach medical invoices, the date of the earliest consultation, the person(s) treated, the name(s) of the medical provider(s), and amount invoiced.
Drop files here or
Max. file size: 2 MB.
    Please attach electronic (original or scanned) copies of invoices from your medical practice.
    DD slash MM slash YYYY
    Please note that any charges that are more than 12 months old are not eligible for reimbursement.
    Summary of attached invoices(Required)
    Person treated
    Provider name
    Amount paid
     
    Please enter at least one row per attached invoice. You may leave "person treated" blank if you are only claiming for yourself.
    Use this space to tell us anything else you think we may need to know, or that you would like to us to know, when processing your request.
    Confirmation

    The following guidelines will be used when your request for assistance is considered and any assistance granted will be at the absolute discretion of the branch.

    Consultation by a GP

    Maximum assistance per visit is $20

    Treatment by GP's nurse

    Maximum assistance per visit is $20.

    Repeat prescriptions

    Maximum assistance per script is $10.

    Further notes

    The levels of assistance may change in the future. Please consider attending our Branch quarterly meetings if you would like to contribute to decisions such as what these levels should be.

    Specialist or other health service providers (such as optmetry, radiology, etc.) do not qualify and will not be considered via this form. However, if you have an expensive medical bill and you feel you have difficulty covering it, and you would like the Branch to consider you for a benevolent grant, please email the Branch secretary outlining your situation.

    Local Medical Fund Application Form (Branch 400)

    Member request for consideration of assistance towards costs of GP visits.

    This field is for validation purposes and should be left unchanged.
    DD slash MM slash YYYY
    Name(Required)
    Please enter a number from 400001 to 400999.
    Hibernians membership number, beginning with 400.
    Address
    Consent(Required)

    Medical invoices

    Please attach medical invoices, the date of the earliest consultation, the person(s) treated, the name(s) of the medical provider(s), and amount invoiced.
    Drop files here or
    Max. file size: 2 MB.
      Please attach electronic (original or scanned) copies of invoices from your medical practice.
      DD slash MM slash YYYY
      Please note that any charges that are more than 12 months old are not eligible for reimbursement.
      Summary of attached invoices(Required)
      Person treated
      Provider name
      Amount paid
       
      Please enter at least one row per attached invoice. You may leave “person treated” blank if you are only claiming for yourself.
      Use this space to tell us anything else you think we may need to know, or that you would like to us to know, when processing your request.
      Confirmation

      The following guidelines will be used when your request for assistance is considered and any assistance granted will be at the absolute discretion of the branch.

      Consultation by a GP

      Maximum assistance per visit is $20

      Treatment by GP’s nurse

      Maximum assistance per visit is $20.

      Repeat prescriptions

      Maximum assistance per script is $10.

      Further notes

      The levels of assistance may change in the future. Please consider attending our Branch quarterly meetings if you would like to contribute to decisions such as what these levels should be.

      Specialist or other health service providers (such as optmetry, radiology, etc.) do not qualify and will not be considered via this form. However, if you have an expensive medical bill and you feel you have difficulty covering it, and you would like the Branch to consider you for a benevolent grant, please email the Branch secretary outlining your situation.