Fillable Online uct ac FORM 10C INFORMATION SHEET FOR - DocHub 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Membership details. Fill in your Membership Number, Type of Cover, Title, Date of Birth, Surname, First Name, and Sex (M/F). If your contact details have changed, provide your Postal Address, Suburb, State, Phone (home), Postcode, Mobile, and Email.
3. In the Claim details section, input the First Name of the patient and their Date of Birth. Specify the Date of Service and the Name of Practitioner or Type of Service. Indicate whether the account has been paid by selecting 'Yes' or 'No'.
4. For Hospital details, confirm if you are claiming medical gap claims for services received as a private inpatient. Enter the From and To dates along with the Hospital name and address.
5. Complete the Accident declaration by indicating if your treatment is associated with an accident/injury. Provide details about your ailment or injury if applicable.
6. In Claim payment section, enter your financial institution's Name and Branch along with Account Holder's name, BSB No., and Account Number. Don’t forget to sign and date this section.
7. Finally, review all information for accuracy before submitting your claim electronically through our platform or via post.

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