Mental Health Subsidy Form

Cystic Fibrosis Queensland Mental Health Subsidy Form

Member Details

Your Full Name

Your email

Your Address

Your Phone Number

I have cystic fibrosisMy child has cystic fibrosisMy partner has cystic fibrosisMy sibling has cystic fibrosis

Name of counsellor or psychologist you will be seeing

To access this subsidy, you need to pay for your appointment, and then provide a copy of your receipt showing the fee and the Medicare rebate along with your private health insurance rebate if eligible. Cystic Fibrosis Queensland will then reimburse the gap fee to the bank account listed below

Reimbursement details
Bank

BSB

Account number

Account name

Supporting evidence
Allowable file formats: (.doc/.docx/.pdf/.jpg/.jpeg/.png)

Any additional information

I declare that all information I have provided to Cystic Fibrosis Queensland is true and accurate. I understand if it is found that I have knowingly provided false or inaccurate information I may no longer be eligible to be a member or receive future services and benefits provided by Cystic Fibrosis Queensland.

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