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Bupa Excess/Co-Payment Reimbursement Application
Please fill in the following application to have your excess/co-payment reimbursed.
Reimbursements generally take around two weeks to process and you will be notified when the application has been approved.
If you have any questions or queries about this please do not hesitate to contact us: 08 8291 2000.
Your Details
Name
*
First
Last
MTA Member Business Name/Member Number
*
Email
Confirm
Phone
*
Claim Details
Bupa Membership Number
*
Hospital amitted to
Date amitted to hospital
*
DD
/
MM
/
YYYY
Claim amount
*
$
Dollars
.
Cents
Copy of Tax Invoice
Please upload a copy of the invoice with the excess/co-payment amount clearly identified. Alternatively please email it with your name to mta@mta-sa.asn.au.
Reimbursement Details
If approved, how would you like to receive your reimbursement.
*
Cheque
Direct Deposit
If you would like us to direct deposit into your account please provide your details below. Alternatively please contact us on 08 8291 2000 or mta@mta-sa.asn.au with these details.
Finanical Institution
BSB
Account Number
Account Name
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