Form Pb048.1505 - Notification Of Bank Account Details For An Approved Community Pharmacy
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1
2Notification of bank account details
for an approved community pharmacy
Purpose of this form
Contact person’s details
Use this form to update or provide your banking details to the
5
Australian Government Department of Human Services (Human
Dr
Mr
Mrs
Miss
Ms
Other
Services) for payments made through online claiming for
Family name
Pharmaceutical Benefits Scheme (PBS).
You will need to allow 10 working days for the change to take effect.
First given name
For more information
For more information, call a Pharmacy Program Officer on 132 290.
6
Daytime phone number
Note: Call charges apply - calls from mobile phones may be charged
(
)
at a higher rate.
Email
Filling in this form
Please use black or blue pen
@
•
•
Print in BLOCK LETTERS
✓
7
•
Mark boxes like this
with a
or
Community pharmacy bank account details
•
Where you see a box like this
skip to the question
Go to 5
7
I would like to:
number shown. You do not need to answer the questions in
between.
Tick ONE only
Register new bank account details
Go to 9
Returning your form
Change bank account details
Go to next question
8
Check that you have answered all the questions you need to answer
If notifying us of a change to bank account details, record the
and that you have signed and dated this form.
old bank account details below.
Send the completed form to:
Name of bank, building society or credit union
Department of Human Services
Pharmacy Approvals
GPO Box 9826
Branch where the account is held
in your capital city
or
Branch number (BSB)
Scan and email to:
nsw.pbs.approval.clerk@humanservices.gov.au
Account number (this may not be the card number)
Community pharmacy details
1
Pharmacy trading name
Account held in the name(s) of
2
PBS approval number
3
Address of pharmacy premises
Postcode
4
Daytime phone number
(
)
1 of 2
PB048.1505 (formerly 4602)
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Parent category: Legal