Please complete the below form to submit your request.Alternatively, you can print and mail in the following form.Click here to download the formMember 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 Account Credit CardFinancial Institution(Bank, Credit Union or Building Society)Account Name*Branch*BSB*Account Number*Effective Date* 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 Select filesMax. file size: 32 MB.NameThis field is for validation purposes and should be left unchanged.
