Online Claiming Provider Agreement (Medicare, Australia)
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4Online Claiming
Provider Agreement
Purpose of this form
Your details
Use this form to apply for online claiming with the Australian
Government Department of Human Services and the Department of
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Dr
Mr
Mrs
Miss
Ms
Other
Veterans’ Affairs.
Family name
You only need to complete one agreement, however bank details
must be provided for each location. To register bank details for
another location use the Banking Details - Online Claiming form
First given name
(HW052). You can download a copy of this form at
humanservices.gov.au/health-professionals/forms/
www.
Second given name
The terms and conditions of this agreement apply at all locations
where you use online claiming to transmit electronically to us.
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Provider number
Who should complete this form
Providers and organisations whose primary role is the provision of
health care services may register to lodge claims electronically.
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If you are not registered with us for a Public Key Infrastructure
(PKI) certificate, go to
humanservices.gov.au/pki
For more information
www.
PKI registration authority (RA number), if applicable.
For more information about online claiming, go to
humanservices.gov.au/healthprofessionals or call 1800 700 199
www.
Monday to Friday, between 8.30 am and 5.00 pm, Australian Eastern
Standard Time.
Application
Note: Call charges apply from mobile phones.
I wish to apply to conduct transactions with the Department of
Human Services electronically using online claiming.
Filling in this form
The terms and conditions of my legal relationship with the
•
Please use black or blue pen
Department of Human Services in respect of transactions conducted
•
Print in BLOCK LETTERS
using online claiming are set out below.
✓
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•
Mark boxes like this
with a
or
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Approved software
When conducting a transaction with the Department of Human
Returning your form
Services using online claiming, I must use a version of a
Check that you have answered all the questions you need to answer
software product approved by the Department of Human
and that you have signed and dated this form.
Services.
I understand that the Department of Human Services may
Send the completed form to:
revoke its approval of a version of a software product at any
Department of Human Services
time. By approving a particular version of a software product,
The Manager
the Department of Human Services is not stating that the
eBusiness Service Centre
product is suitable for any purpose or that the product meets
GPO Box 9822
any quality standards.
In your capital city
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Public Key Infrastructure (PKI)
or
I must ensure that all communications I send to the Department
Scan and email to: ebusiness@humanservices.gov.au
of Human Services using online claiming are signed and
or
secured with a Medicare PKI Site certificate.
Fax: 03 9605 7981
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Privacy
I must not send any personal information (as defined in the
Privacy Act 1988) to the Department of Human Services using
online claiming unless the information is encrypted using PKI.
1 of 4
HW027.1503 (formerly 2235)
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