Authority to Access Membership

Authority to Access Membership Request Form

As the Primary Member (policy holder) you can authorise your spouse/partner to operate your policy as though they are the Primary Member with the exception of removing dependants from your policy or terminating the policy.
You can also authorise another person to make enquiries about your insurance policy.
You may change or withdraw this authority at any time by advising our office in writing or by phoning our Customer Contact Centre on 1300 661 283.

By completing this form, you agree to the Union Health Terms and Conditions and declaration listed on the form.

If you'd like to view how we collect and store your information you can view our privacy policy here.

Member name *

Membership number *

Request type *

Spouse/partner authority to act (must be on membership)

Third party authority to enquire

Spouse/partner authority to act

Complete this section to authorise your spouse/partner to access your membership. For more information regarding the rights your spouse/partner has on your policy, please click here.

To act on my behalf, I appoint my spouse/partner:

First name

Last name

I agree that Union Health may: • Seek information from this person • Provide information to this person • Act on instruction from this person. Union Health will act on requests received via email, telephone, in writing and in person *

Yes

Third party authority to enquire

Complete this section to authorise a third party to make enquiries about your insurance policy. This appointment does not entitle the person to make any changes to, or terminate, this policy. The information you provide in this section will enable us to verify the identity of a third person making enquiries about your health insurance policy.

I authorise:

First name

Last name

Address

Relationship to member

Date of birth

Day

Month

Year

To access my personal information, including financial, medical and health information that Union Health holds and obtains in connection with my policy.

Declaration

I consent to Union Health collecting, using and disclosing personal information in accordance with its Privacy Policy. I understand and agree that this appointment does not entitle the person nominated to terminate this policy. I agree to make the Authorised Person aware of this nomination.

Please note: To appoint a third person to make transactions on your policy, Union Health requires you to provide a copy of a valid Enduring Power of Attorney, as made under the Powers of Attorney Act 1998 (Qld). As a decision to change or terminate membership may result in a member being unable to access or continue treatment, which is a health matter, the decision should be made by an attorney appointed under a power of attorney for personal matters including financial and health care.

Check Union Health's privacy policy here.