Application Form For An Additional Location Medicare Provider/ Registration Number Page 5

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Application for an additional
location Medicare provider/registration number
Health profession
Tick where applicable ✓
Select the health profession category for which a provider/
Personal details
registration number is required:
Dr
Mr
Mrs
Miss
Ms
Medical Practitioner
Psychologist
Other (please specify)
Optometrist
Social Worker
1
Family name
Aboriginal Health
Speech Pathologist
Worker
First given name
Audiologist
Dentist
Other given names
Chiropodist
Dento-Maxillofacial
Radiologist
Chiropractor
Endodontist
2
Date of birth
/
/
Dental Prosthetist
Oral and Maxillofacial
Surgeon
3
Your sex
Diabetes Educator
Oral Medicine and/or
Oral Pathologist
Male
Dietitian
Oral Surgeon
Female
The following question is to be completed by medical
Exercise Physiologist
Orthodontist
practitioners only:
4
Were you born in Australia?
Mental Health Nurse
Paedodontist
If no, please specify if you are:
No
Occupational
Periodontist
Australian citizen
Therapist
Osteopath
Prosthodontist
/
/
Date granted
Permanent resident
Physiotherapist
Special Needs Dentist
/
/
Date granted
Podiatrist
Temporary resident
Personal contact details
(includes NZ citizen)
6
Postal and/or email address to be used for:
Yes
This application only
5
Please quote an existing provider/registration number
General correspondence
Medicare Australia has issued to you (not those issued
by the Department of Veterans’ Affairs or Office of
Postal address
Hearing Services.
Postcode
Email
@
Page 5 of 6
1413.26.10.07

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