3.2 Dental Health form

Community Programs

Program 3: HEALTH AND WELLBEING

3.2 Dental 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 details

All Dependent Children must be registered with IBN using the Dependent Child Advice Form. Only the IBN parent or legal carer of a dependent child may apply for benefits to assist the child.

IBN member or legal carer’s full name(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Language Group(Required)

Yinhawangka

Banyjima

Nyiyaparli

Patient’s full name(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Current home address

Postcode

Phone

Email address

My address or other personal details have changed.

Please complete an ‘Update personal details’ form and attach it to your application.

Patient’s Medicare Number(Required)

Name of private health fund

Private health fund number

Items for purchase (NO CASH PAYMENTS)

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)

List(Required)

Description of item

Supplier

Amount

Comments

Required Documents

Copy of Medicare card
Doctor’s certificate, prescription or referral
Dental treatment plan from a registered dentist
Copy of private health insurance policy (if applicable)
Copy of Ambulance cover (if applicable)

Copy of travel insurance policy (if applicable)
Supplier quotes or invoices including payment details
IBN Dependent Child Advice Form (if required)
IBN Update Personal Details form (if required)

Upload Documents

Drop files here or

Max. file size: 50 MB.

Declaration (Required)

I declare that:

the information I have provided in this form is true and correct.
the benefits are for my own use or for my own child or a dependent child who is legally in my care.

Agreement(Required)

I agree that IBN may share my information with other organisations for application assessment purposes.

Community Programs

Program 3: HEALTH AND WELLBEING

3.2 Dental Health

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