Request for refund -

Use the form below to request a refund as:

If you have any questions about fee exemptions, please contact NSW Ambulance customer service team on 1300 655 200.

Personal information

Patient’s given name *

Patient’s surname *

Patient’s date of birth *

Day Month Year

Person who paid the account *

Relationship to patient *

Invoice number (if known)

Contact information

Email * Please enter your email address.

Street address *

Address line 2

City *

State

Postcode *

Attachment * A copy of your payment receipt must be attached. File types include PDF, Word and image files.

Declaration

I certify the above details are true and correct and confirm my eligibility for a refund (please select Yes). *