Online Claiming Banking Details

Online Claiming Banking Details

Location ID

(minor customer ID)

Note:

This form should only be completed by the Payee Providers of the above stated Location ID.

If you are also the Payee Provider of a different location, please complete another form with that Location ID.

For assistance please call the Medicare Australia eBusiness Service Centre on 1800 700 199

Part A Practice Details

Practice name

Practice address

Postcode

(

)

Contact name

Phone

PA

Part B Bank details for electronic funds transfer for Online Claiming

Note:

You must complete a separate form for each account that you want funds transferred to.

The following account details are to be used for the providers listed in Part C, effective from

/

/

Account name

Bank

Branch

BSB no. (six digits)

Account no. (nine digits)

What type of online transactions do you want paid to this account?

Tick applicable box/es

Medicare Bulk Bill /DVA Claims

ACIR Claims

Part C Payee Provider details

Provider name

Provider number

Provider’s signature

Please return completed form to:

Manager

eBusiness Service Centre

GPO Box 9822

In your capital city

Privacy Note: The information provided by you on this form will be used by Medicare Australia to register your nominated financial institution details for the purposes of

making electronic payments as detailed on this form. Your financial institution account details will be disclosed to the relevant financial institutions to facilitate your request.

Online Claiming Banking Details Feb 06