Application For An Initial Medicare Provider/ Registration Number For An Allied Health Professional (Page 3 of 3) in pdf

Application For An Initial Medicare Provider/ Registration Number For An Allied Health Professional Page 3

Bank account details

State or territory of registration/membership

All payments are made through Electronic Funds Transfer (EFT).

Payments cannot be made via EFT if the nominated account has

Registration/membership number

restrictions on EFT deposits.

Name of bank, building society or credit union

Date registered

Branch where the account is held

Registration/membership number

Branch number (BSB)

Attach a copy of documents confirming registration/

membership with the relevant State or Territory Board

or membership of a National Professional Association

Account number (this may not be the card number)

or relevant qualifications.

Account held in the name(s) of

Required location

A location is the physical location (not post office box) and is the

address at which you render services.

If you are applying for more than one location attach a

Privacy notice

separate sheet with details from questions 13–19 for

Your personal information is protected by law, including the

each location.

Privacy Act 1988, and is collected by the Australian Government

Department of Human Services for the assessment and

Start date

End date

administration of payments and services. This information is

required to process your application or claim.

Your information may be used by the department or given to

Practice address and email (if different to question 5)

other parties for the purposes of research, investigation or

Practice name or building

where you have agreed or it is required or authorised by law.

You can get more information about the way in which the

Department of Human Services will manage your personal

Property or department

information, including our privacy policy at

humanservices.gov.au/privacy or by requesting a copy from

www.

the department.

Unit

Suite

Shop

Floor number

Declaration

Street number

I declare that:

•

I am entitled to render professional services as defined in

Street name

the Health Insurance Act 1973 and apply to have Medicare

benefits paid directly into the account mentioned on this

form.

Suburb

•

the information I have provided in this form is complete and

correct.

I understand that:

State

Postcode

•

giving false or misleading information is a serious offence.

Applicant’s signature

Practice phone number

(

)

Fax number

Date

(

)

Is this location an Aboriginal or Torres Strait Islander Health

Service?

Yes

Does your registration allow you to work at this location?

Yes

3 of 3

HW063.1503 (formerly 1449)

Application For An Initial Medicare Provider/ Registration Number For An Allied Health Professional Page 3

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