Fields on page 2
What would you
1.App Sub
Existing provider number
1.App Reopen
Currently closed provider number
1.App Close
Provider number for location
Address for location
Address for location
1.App PostalAdd3
Postcode
Location end date
end date (DD MM
date (DD MM YYYY)
1.App Prescriber
Provider number
Dr
Mr
Mrs
Miss
Ms
Mx
1.App SalutOther
Family name
First given name
Second given name
Your date of birth
date of birth (DD MM
birth (DD MM YYYY)
Male
Female
Non-binary
Languages spoken (other than English)
Postal address
Postal address
1.App PostalAdd3A
Postcode
Business phone number (including area code)
Mobile phone number
Email
Fields on page 3
What is your
Australian
Date you became an
you became an
an Australian citizen (DD
or
Date you became a provide date of birth)
you became a date of birth) (DD MM
a permanent resident (if of birth) (DD MM YYYY)
or
No
Yes
No
Yes
Primary medical qualification
Country obtained
Medical school
Year obtained (YYYY)
No
Yes
No
Yes
Bonded Medical Program
– Legacy program
– Legacy program
Ahpra registration number
No
Yes
Specialist or consultant physician recognition with Medicare
Specialist registration as a general practitioner through Ahpra
Fields on page 4
No
Yes
Location start date
start date (DD MM
date (DD MM YYYY)
Location end date
end date (optional)
date (optional) (DD MM YYYY)
No
Yes
No
Yes
No
Yes
Organisation Site ID
No
Yes
No
Yes
Practice or hospital name
Unit
Suite
Shop
Floor number
Street number
Street name
Is this a government funded Aboriginal and Torres Strait Islander
State
Postcode
Is this a government funded Headspace Centre and the services
Email
Refer and request only (such as hospital interns)
of Veterans’ Affairs rebateable services
Refer, request and assist at private operations only
Fields on page 5
Individual proprietor
Sole trader
Joint owner in a partnership
Salaried
Contracting organisation
Australian Business
Business Number
Number (ABN)
(ABN)
Australian Company
Company Number (ACN) (if
Number (ACN) (if applicable)
This must match the details as they appear in the entity name field on the Australian Business Register.
Individual proprietor
Partnership
Unincorporated association
Company
State government
Territory government
Other public body
Hospital - public
Hospital - private
Practice - general practice
Practice - other private practice
Educational institution
Residential care facility
Other community health care service
Home
Mobile
No
Yes
Practice Management Software Location ID
No
Yes
Name of the financial institution that supplied the EFTPOS device
Name of bank, building society or credit union
Branch number (BSB)
Account number (this may not be the card number)
Account held in the name(s) of
A copy of your current medical registration certificate if
Evidence of your current residency status, if applying for
Evidence of your residency status at your date of
A copy of your current medical registration.
Personal pages of your passport and current visa status.
A letter of support from your employer as to why you
A copy of the medical board registration from the date of
If applying for more than one location, complete questions
