Rural Other Medical Practitioners (Romps) Programme Registration Form - Australian Department Of Health Page 2

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Rural Other Medical Practitioners (ROMPS) Programme Registration Form
1. Personal Details
Please enter your full name as provided on your medical registration.
Family Name:
Given Name(s):
2. Current Status (Please tick appropriate boxes)
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☐
☐
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Non VR medical practitioner
OTD
TRD
Locum
Other
If Other, Please Specify:
3. Practice Locations & Provider Numbers
In order to process your application, the FULL street address of each practice location is
required.
Rural, Remote and Metropolitan Areas
(RRMA) classifications can be obtained by contacting
Medicare Australia on 1800 032 259
Provider Number:
RRMA:
Practice Name:
Suite:
Level:
Building:
Street Number:
Street Name:
Locality/Town:
Postcode:
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