Apply for a MediPay Easy Payment Plan Now | Dental, Cosmetic & Medical

Will a parent or your spouse help you make the repayments?*

No Yes

In the case of parents, children must be under the age of 25 years. In the case of your partner, you must be married or in a de-facto relationship and reside at the same address.

What's their name?*

Enter their full name here.

Enter their email*

You are required to insert their email to complete the application. We'll send them an email with a link to complete the application once you submit this form. If your co-applicant has already completed an application please insert their email address so we can attach your application to theirs as a joint application.

Is the procedure for you?*

No Yes

Confirm if the procedure is for you.

They will need to complete the application form separately as well. Would you like us to send them an email with link to the application?

Have you decided on a doctor/clinic for your procedure?*

No Yes

Or if the procedure is for your pet then have you decided on a vet?

What is the name of the doctor or clinic?*

If for your pet insert the name of vet or clinic.

When do you think you will need the funds?*

An estimated date is fine

Employment

Employment Details

Employment status*

Full time Part time Casual/Temp Contractor Self-employed Stay-at-home partner Retired Unemployed None of the above

Please provide more detail about your employment status*

Select the industry sector related to your main employment

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About your employer

Job title*

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How long have you worked here?*

2 years or more Between 1 and 2 years Between 3 and 12 months Less than 3 months

Employer business name*

Employer phone number

Please include area code. We'll use this to confirm your employment status.

About your previous employer

Previous employment job title*

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Previous employer business name*

Previous employer phone number

Please include area code

Self-employment details

How long have you been self employed?*

2 years or more Between 1 and 2 years Between 3 and 12 months Less than 3 months

As part of verification we will ask you to provide your two most recent ATO Notice's of Assessment

Business name*

Business ABN*

Your accountant's name

Your accountant's phone number

Address details

Your Address Details

Enter Your Address

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Address*

Address Line 1

Address Line 2

City

State

Postcode

How long have you lived at this address?*

2 years or longer Less than 2 years

Enter Your Previous Address

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Previous address*

Address Line 1

Address Line 2

City

State

Postcode

What is your home ownership status – i.e. do you own or rent your home?

Renting I own it - paying off mortgage I own it - mortgage already paid Not paying rent- living with family Other

Pick one option that best applies to you. If you're unsure, choose 'Other'

You chose the 'other' option in the previous field – please explain your home ownership status*

Relationship status*

Single De facto Married Divorced or separated Widowed

Monthly living expenses
Groceries	$
Clothing & Personal Care	$
Education	$
Childcare & Pets	$
Insurance	$
Entertainment	$
Medical and Health Care	$
Utilities	$
Transport	$
Communication	$
Other	$
Total monthly living expenses	$

Your Income & expenses

Your Income & Expenses

What is your gross annual salary (before tax or super)? Check your payslip or employment contract if you're unsure.* A$

Don't include commissions, super or bonuses here – just your fixed base salary. Minimum gross annual salary is $25,000. (ONLY insert numbers - NO commas, fullstops or dollar signs)

How often do you get paid?*

Weekly Fortnightly Monthly

Do you receive a payment from Centrelink?*

No Yes

Including Age Pension, Disability Support Pension and Family Tax Benefit or any other Centrelink payment

How many types of payments do you receive from Centrelink?

Centrelink payment 1 type*

Centrelink payment 1 fortnightly amount* A$

Add another Centrelink payment

Centrelink payment 2 type*

Centrelink payment 2 fortnightly amount* A$

Add another Centrelink payment

Centrelink payment 3 type*

Centrelink payment 3 fortnightly amount* A$

Please provide details on Centrelink payment type 3+ and how much income you receive from each additional source fortnightly

Do you have any other source of income?*

No Yes

Like bonuses, commission, interest, dividends or a second job. Do not include rental income from investment property as this is asked for below.

If you selected that you receive a Family Tax Benefit please provide the ages of all your dependants (Please insert a comma between the ages)

How many sources of other income do you have?

Source 1 type*

Source 1 monthly amount* A$

Add another source of income

Source 2 type*

Source 2 monthly amount* A$

Add another source of income

Source 3 type*

Source 3 monthly amount* A$

Add another source of income

Source 4 type*

Source 4 monthly amount* A$

Add another source of income

Source 5 type*

Source 5 monthly amount* A$

Add another source of income

Please provide details on sources 6+ and how much income you receive from each additional source every month

Don't include rental income here

What are your general household monthly living expenses?* A$

Include all your household monthly living expenses that you pay each month. Include: Childcare; Clothing & Personal Care; Education; Groceries; Insurances; Medical & Health Care; Travel, Recreation & Entertainment; Communications; Transportation; Utilities and any other household costs. DO NOT include rent, mortgage or loan repayments since these are asked for in other fields.

What are your total household monthly living expenses?* A$

Include all your household monthly living expenses that you pay each month. Include: Childcare; Clothing & Personal Care; Education; Groceries; Insurances; Medical & Health Care; Travel, Recreation & Entertainment; Communications; Transportation; Utilities and any other household costs. DO NOT include rent, mortgage or loan repayments since these are asked for in other fields.

What percentage of your total household monthly living expenses does your spouse or partner pay each month?

From 0% - 19% From 20% - 49% 50% or more

How often do you pay rent or mortgage on your home?*

Weekly Fortnightly Monthly

This is only about the home you live in - not investment properties

How much rent or mortgage do you pay each time? Include your partner or spouse contribution (if any).* A$

This is only about the home you live in - not investment properties

What percentage of your rent or mortgage does your spouse or partner pay each time?

From 0% - 19% From 20% - 49% 50% or more

What is the estimated value of your home?* A$

How much is your home currently worth (estimate)?

What is the amount owing on your mortgage?* A$

Latest balance owing on your home loan

Do you expect any significant change to your financial situation over the next 6 to 12 months that would ADVERSELY impact your ability to meet loan repayments?*

No Yes

Your assets & liabilities

As a responsible provider of payment plans, we need to ensure our payment plans are offered only to those that can afford them. This is good for both you, and us. The questions below help us understand your financial situation better.

Do you own any investment property?*

No Yes

Other than the home you live in

Property 1: What is your monthly rental income from this property? A$

Property 1: Are you making mortgage repayments on this property?

No Yes

Only for this property

Property 1: How much is the monthly mortgage repayment? A$

Only for this property

Property 1: What is the amount owing on the mortgage? A$

Latest balance owing for this property only

Add another property

Property 1: What is the estimated value of this property?

Property 2: What is your monthly rental income from this property? A$

Property 2: Are you making mortgage repayments on this property?

No Yes

Only for this property

Property 2: How much is the monthly mortgage repayment? A$

Only for this property

Property 2: What is the amount owing on the mortgage? A$

Latest balance owing for this property only

Add another property

Property 2: What is the estimated value of this property?

Property 3: What is your monthly rental income from this property? A$

Property 3: Are you making mortgage repayments on this property?

No Yes

Only for this property

Property 3: How much is the monthly mortgage repayment? A$

Only for this property

Property 3: What is the amount owing on the mortgage? A$

Latest balance owing for this property only

Property 3: What is the estimated value of this property?

Please provide the estimated value, latest loan balance (if any) and monthly mortgage repayments for all additional properties

One per line

Do you own any other non-property assets?*

No Yes

Like a car, shares or any other major items.

Please list your non-property assets and their estimated value.

If you're unsure, include it anyways.

Asset 1: Type

Asset 1: Estimated value A$

Add other asset

Asset 2: Type

Asset 2: Estimated value A$

Add other asset

Asset 3: Type

Asset 3: Estimated value A$

Add other asset

Asset 4: Type

Asset 4: Estimated value A$

Do you have credit cards?*

No Yes

Please include storecards e.g. MYER, DJs, Gem Visa, GO MasterCard

Card 1 Provider

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Card 1 credit limit* A$

Card 1 Amount owing* A$

If you pay it off in full at the end of each month, enter 0, otherwise enter the current balance owed

Add another credit card

Card 2 Provider

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Card 2 credit limit* A$

Card 2 Amount owing* A$

If you pay it off in full at the end of each month, enter 0, otherwise enter the current balance owed

Add another credit card

Card 3 Provider

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Card 3 credit limit* A$

Card 3 Amount owing* A$

If you pay it off in full at the end of each month, enter 0, otherwise enter the current balance owed

Add another credit card

Card 4 Provider

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Card 4 credit limit* A$

Card 4 Amount owing* A$

If you pay it off in full at the end of each month, enter 0, otherwise enter the current balance owed

Add another credit card

Card 5 Provider

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Card 5 credit limit* A$

Card 5 Amount owing* A$

If you pay it off in full at the end of each month, enter 0, otherwise enter the current balance owed

Please provide details about each additional card - include the credit limit and amount owing for each

Please include all storecards e.g. Myers, DJs, Gem Visa, GO MasterCard

Do you have any other debt?*

No Yes

Like unpaid overdrafts, car loans, personal loans, etc.

One: What type of debt?

Eg: Overdraft, personal loan, car loan, etc.

One: How much is still owing?* A$

Eg: 16000

One: What is the monthly repayment?* A$

Eg: 800

Add another debt

Two: What type of debt?*

Eg: Overdraft, personal loan, car loan, etc.

Two: How much is still owing?* A$

Eg: 16000

Two: What is the monthly repayment?* A$

Eg: 800

Add another debt

Three: What type of debt?*

Eg: Overdraft, personal loan, car loan, etc.

Three: How much is still owing?* A$

Eg: 16000

Three: What is the monthly repayment?* A$

Eg: 800

Add another debt

Four: What type of debt?*

Eg: Overdraft, personal loan, car loan, etc.

Four: How much is still owing?* A$

Eg: 16000

Four: What is the monthly repayment?* A$

Eg: 800

Add another debt

Five: What type of debt?*

Eg: Overdraft, personal loan, car loan, etc.

Five: How much is still owing?* A$

Eg: 16000

Five: What is the monthly repayment?* A$

Eg: 800

Please provide details on all additional debts

The type of debt, the total amount and monthly repayments.

Your ID

Date of birth*

Do you have an Australian driver's license?*

No Yes

Driver's license state*

ACT NSW NT QLD SA TAS VIC WA

Driver's license number*

Medicare card number*

Include the number before your name with no spaces - 11 digits total

What colour is your Medicare card?*

Green Blue Yellow

What is the expiry (valid to) date on your Medicare card?*

How many dependants do you have*

0 1 2 3 4 or more

Dependant 1: Age

Dependant 2: Age

Dependant 3: Age

Dependant 4: Age

Your declaration

Your Declaration

Are you an Australian citizen or Permanent Resident?*

Yes

Do you declare all the information that you have provided in this application to be true and correct?*

Yes, I declare all information that I have provided in this application is true and correct.

Do you give us consent to check your credit history and verify your identity?*

Yes, I give MediPay consent to give my personal and credit information to credit reporting agencies, including Equifax, for the purpose of obtaining a consumer and commercial credit eligibility report about me to assess my creditworthiness, and to otherwise deal with any information I provide in accordance with your Privacy Policy and Credit Reporting Policy. Our policy contains information about us, the types of information we collect and why, how we treat your personal and credit information, who we disclose it to, how you may access and correct your information, how you may complain or contact the credit reporting body we use, what happens if you fail to meet your repayments or commit a serious credit infringement, what happens if you believe you may have been a victim of fraud, and other notifiable matters. I also consent to my personal details being checked with the document issuer or official record holder (e.g. Government agency) via a third party (e.g. an identity checking service) for MediPay to verify my identity.

Do you give us consent to send you notices and documents electronically and signing documents electronically?*

You consent to be given notices and other documents in connection with our dealings with you electronically (including by email to your address provided). By consenting, you warrant that you have an ability to save and print the documents, and you understand that: (a) paper documents may no longer be given; and (b) electronic communications must be regularly checked for documents; and (c) consent to the giving of documents by electronic communication may be withdrawn at any time.

Click here to view our privacy policy

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Campaign Name

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Procedure

Employment Details

Your Address Details

Your Income & Expenses

Your ID

Your Declaration