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 Member DetailsMember Number*Member Name*Address*Postcode*I / we request Cessnock District Health Benefits Fund Dr - 088892 to arrange for funds to be Debited from my nominated financial institution shown below. Please note: Joint Accounts require both signatures.Signature*Person OneSignaturePerson TwoPayment Type*Bank AccountCredit CardFinancial Institution(Bank, Credit Union or Building Society)Account Name*Branch*BSB*Account Number*Effective Date* Date Format: DD slash MM slash YYYY Credit Card DetailsA member of the CDHBF team will contact you to confirm your new Credit Card details following submission of this form.Please upload all relevant attachements with your claim...Attach Files Drop files here or PhoneThis field is for validation purposes and should be left unchanged.
