Community Programs Program 3: HEALTH AND WELLBEING 3.1 General Health These programs provide support for members and dependent children for a range of medical or dental expenses as prescribed by a doctor or dentist. Applicant detailsHealth(Required) 3.1 GENERAL MEDICAL 3.2 DENTAL HEALTH 3.3 MEDICAL AND DENTAL TRAVEL 3.4 HOME RENOVATIONS FOR ELDERS & DISABLED IBN Member’s full name(Required) Membership Number: Date of Birth(Required) DD slash MM slash YYYY Registered home address(Required) Phone Email Address Language Group(Required) Yinhawangka Banyjima Nyiyaparli Patient’s Full Name: Date of Birth(Required) DD slash MM slash YYYY Relationship: Patient’s Medicare Number: What is the reason applying? Have you applied to PATS or other sources for assistance? Yes No For details on what expenses IBN will cover please see the IBN 2022-23 Community Programs Handbook, or the IBN website: www.ibngroup.com.au(Required)Description of item (what is the money for?)Name of supplierAmount Add RemoveHiddenTotal CommentsDeclaration (Required)Declaration(Required) I declare that the information I have provided in this form is true and correct. I agree that IBN may share my information with other organisations for application assessment purposes.