Stanley Hospital Refund Details Bank Account BSB: __ __ __ - __ __ __ Please select either bank Account Name: ______________________________ account or credit card for refund. Account Number: ______________________________ Please note: If the original Bank and Branch: ______________________________ payment was by credit card, OR this refund must be to the Your BPAY Biller Code: ___________ same credit card using the BPAY information found on Your BPAY Reference Number: ________________________ your Credit Card statement I confirm that the information provided above is accurate and acknowledge that Fiona Stanley Hospital will determine the final balance on the card and are not liable for any incorrect information including incorrect banking or credit card details that are provided. Name:_______________________ Signature: __________________ Date: ___________ Office Use Only: Received: Processed: Authorised: Reference: Amount:
Stanley Hospital Refund Details Please select either bank account or credit card for refund. Please note: If the original payment was by credit card, this refund must be to the same credit card using the BPAY information found on your Credit Card statement Bank Account BSB: __ __ __ - __ __ __ Account Name: ______________________________ Account Number: ______________________________ Bank and Branch: ______________________________ OR Your BPAY Biller Code: ___________ Your BPAY Reference Number: ________________________ I confirm that the information provided above is accurate and acknowledge that Fiona Stanley Hospital will determine the final balance on the card and are not liable for any incorrect information including incorrect banking or credit card details that are provided. Name:_______________________ Signature: __________________ Date: ___________ Office Use Only: Received: Processed: Authorised: Reference: Amount:
FSH-PES-FRM-0001%20-%20Patient%20Entertainment%20-%20Patient%20Entertainment%20Refund%20002.docx