Page 1

4 fields

Fields on page 1

for a new APP

to renew an existing APP

to amend an existing APP

Page 2

41 fields

Fields on page 2

APP number

Mrs

Miss

Other

Family name

First given name

Postal address

1.App PostalAdd3

Postcode

Daytime phone number (including area code)

Mobile phone number

This is the email address we will use to notify you of the outcome of your application.

Mrs

Miss

Other

Contact person’s full name

Position held

Daytime phone number (including area code)

Mobile phone number

Australian Health Practitioner Regulation Agency (Ahpra) registration number

Registration expiry

expiry date (DD

expiry date (DD MM YYYY)

Qualification

Institution

Year attained (YYYY)

Qualification

Institution

Year attained (YYYY)

Qualification

Institution

Year attained (YYYY)

Page 3

46 fields

Fields on page 3

Link a new APL to this APP

Unlink an APL from this APP

APL number

Your provider number at this APL location

Date of effect of this

of effect of this change

of this change (DD MM YYYY)

Laboratory name

Building name

Unit

Suite

Shop

Floor number

Street number

Street name

Suburb or town

State

Postcode

Yes

1.APL Hidden1

Yes

Link a new APL to this APP

Unlink an APL from this APP

APL number

Your provider number at this APL location

Date of effect of this

of effect of this change

of this change (DD MM YYYY)

Laboratory name

Building name

Unit

Suite

Shop

Floor number

Street number

Street name

Suburb or town

State

Postcode

Yes

1.APL Hidden2

Yes

Page 4

46 fields

Fields on page 4

Link a new APL to this APP

Unlink an APL from this APP

APL number

Your provider number at this APL location

Date of effect of this

of effect of this change

of this change (DD MM YYYY)

Laboratory name

Building name

Unit

Suite

Shop

Floor number

Street number

Street name

Suburb or town

State

Postcode

Yes

1.APL Hidden3

Yes

Link a new APL to this APP

Unlink an APL from this APP

APL number

Your provider number at this APL location

Date of effect of this

of effect of this change

of this change (DD MM YYYY)

Laboratory name

Building name

Unit

Suite

Shop

Floor number

Street number

Street name

Suburb or town

State

Postcode

Yes

1.APL Hidden4

Yes

Page 5

14 fields

Fields on page 5

Yes

If you have answered ‘Yes’ to any of questions (a) to (f) at question 10, give details of name, company name and provider number (if applicable).

Provide any additional information to support this application

Page 6

1 field

Page 10

18 fields

Fields on page 10

I (full name in block letters)

a medical practitioner who is or wishes to become an approved pathology practitioner, of (full address)

pathology practitioner, of (full address)

1.App Add3

Postcode

Medical practitioner’s signature

Date (DD MM YYYY)

(DD MM YYYY)

YYYY)

I (full name of witness in block letters)

of (full address)

1.Wit Add3

Postcode

Date (DD MM YYYY)

(DD MM YYYY)

YYYY)

Healthcare Federal · HW009

Application for approval, amendment or renewal of an approved pathology practitioner (HW009)

This form is used by pathology practitioners to apply for, amend or renew their approved pathology practitioner status under the Health Insurance Act 1973.

Issued by: Services Australia
Form number: HW009
Jurisdiction: Federal
Length: 10 pages

When do you need this form?

You need this form if you are a pathology practitioner who wants to become an approved pathology practitioner (APP) for the first time, or if your existing APP approval is expiring and needs renewal. You also use this form to make changes to an existing APP approval, such as linking or unlinking accredited pathology laboratories.

What you'll need

Current Australian Health Practitioner Regulation Agency (Ahpra) registration details
Recognition as a specialist or consulting physician recorded with your provider number
Current agreement, arrangement or contract with the proprietor of the accredited pathology laboratory (if you are not the proprietor)
APP number (if amending or renewing existing approval)
Letter explaining reasons for late application (if applicable)

Where to send it

Submit the completed form online using your PRODA account and the Form upload function in Health Professional Online Services (HPOS), or post all pages to Services Australia Pathology Approvals, GPO Box 9822, SYDNEY NSW 2000. The form must be physically signed, dated and witnessed unless otherwise indicated.

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