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M Direct Debit

Please complete the below form to submit your request.

Alternatively, you can print and mail in the following form.

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  • Member Details

  • 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.
  • Person One
  • Person Two
  • Financial Institution

    (Bank, Credit Union or Building Society)
  • Credit Card Details

  • A 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...

  • Drop files here or
  • This field is for validation purposes and should be left unchanged.

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