Please complete the below form to submit your request. Alternatively, you can print and mail in the following form. Click here to download the form All Australian registered health funds are required to issue you with a clearance certificate when you cancel your health cover with them. This is to ensure any waiting periods have been served and to recognise your Lifetime Health Cover details. To allow us to obtain these details and/or advise your previous Health Fund your intentions to transfer your cover to us, please complete the details below and sent this form (signed and dated) to the above address via mail, scanned email or fax. Members DetailsFirst Name*Last Name*Address* Street Address City State Post Code Contact Details(H)(M)*(W)Previous Health Fund DetailsPrevious Fund Name*Policy No. (if Known)Effective Date* Date Format: DD slash MM slash YYYY Date Paid to* Date Format: DD slash MM slash YYYY DependantsPlease list all dependants*NameD.O.B Click the + icon to add moreNew Fund DetailsFund Name: CDHPolicy No. (If Known)Start Date Date Format: DD slash MM slash YYYY I hereby authorise CDH on my behalf to obtain the Clearance Certificate and cancel my membership including any payment arrangements withfrom the start date of my policy with Cessnock District Health Benefits Fund.Please upload all relevant attachements with your claim...Attach Files Drop files here or SignatureNameThis field is for validation purposes and should be left unchanged.