Please provide your existing fund details below If you are transferring from another health fund we will arrange for the transfer for you, by submitting this form, it gives us permission to contact your previous fund to obtain your cover details. If you are transferring to an equivalent level of cover with equivalent benefits, you will not have to re-serve your waiting periods. If you have cancelled your health insurance membership with another health fund, you will need to join Nurses & Midwives Health within 60 days to make sure you receive continuity of cover. Benefits cannot be paid until your previous fund forwards a certificate of clearance to Nurses & Midwives Health and your membership has been paid to the date of service.If you and your partner are transferring from separate memberships, you will each need to complete a Clearance Certificate Request. Nurses & Midwives Health member no.: Previous fund name * Previous membership number Full name * Date of birth * Please provide information to Nurses & Midwives Health about * Myself My partner My dependants Date of existing fund termination * By submitting this form, I hereby authorise Nurses & Midwives Health to terminate my membership from the above mentioned date with my existing fund and / or obtain details about my membership.* * indicates mandatory fields I AM NOT A ROBOT
