Page 2

44 fields

Fields on page 2

APA number

APA name

Mrs

Miss

Other

Dr Mr Mrs Miss Ms Mx Other Authorised representative’s full name

Position held

Provider Digital Access (PRODA) Registration number

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

1.AR2 SalutOther

Dr Mr Mrs Miss Ms Mx Other Authorised representative’s full name

Position held

PRODA RA number

Daytime phone number (including area code)

Mobile phone number

for a new ACC

to renew your ACC

to amend an existing ACC

to cancel an existing ACC

Proposed start date

start date (DD MM

date (DD MM YYYY)

ACC number

Trading name

ACC address

1.ACC Add3

Postcode

Yes

Provide APL number

Page 3

78 fields

Fields on page 3

Yes

the lessee

the sublessee

the owner

following an acquisition or merger

lessee

sublessee

owner

Previous APA number Previous

Previous ACC number

Lessor or sublessor name

Lessor or sublessor postal address

1.Lease PostAdd3

Postcode

Lease/Sublease start

start date (DD

start date (DD MM YYYY)

Lease/Sublease end

end date (DD

end date (DD MM YYYY)

Yes

First option

year(s)

months

Second option

year(s)

months

Third option

year(s)

months

From (DD MM YYYY)

of the lease/sublease in question 16.

lease/sublease (incl GST), 16.

To (DD MM YYYY)

in question 16.

16.

From (DD MM YYYY)

1.Lease RentTo21

1.Lease RentTo22

1.Lease RentTo23

From (DD MM YYYY)

To (DD MM YYYY)

Yes

Year

Description

Year

Description

1.Lease Year3

1.Lease Description3

Year

Description

Percentage

Year

Description

1.Lease UnknownYear3

1.Lease UnknownDescript3

Yes

Area of premises in m2

Include any additional area in

Page 4

14 fields

Fields on page 4

Physical address of additional area (floor, level, street address)

1.Lease PhysicalAdd3

Postcode

Payment/Remittance advice

Lease/Sublease

Floor plan

Proof of ownership of the premises

If your ACC has expired, a letter of request telling us why

• giving false or misleading information is a serious offence. Authorised representative’s full name

Date (DD MM YYYY)

and sign by hand.

sign by hand.

Authorised representative’s signature (authorised to sign on behalf of the approved pathology authority)

Page 5

25 fields

Fields on page 5

ACC number

ACC physical address

1.ACC Add13

Postcode

ACC closure date

closure date (DD MM

date (DD MM YYYY)

No longer in operation

Relocation

APA merger/acquisition

ACC opened in error

Other

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

Authorised representative’s full name

Date (DD MM YYYY)

(DD MM YYYY)

YYYY)

Authorised representative’s signature (authorised to sign on behalf of the approved pathology authority)

Healthcare Federal · HW035

Application for Approved Collection Centre (HW035)

This form is used by approved pathology authorities to apply for, renew, amend or cancel an approved collection centre.

Issued by: Services Australia
Form number: HW035
Jurisdiction: Federal
Length: 5 pages

When do you need this form?

You need this form if you are an approved pathology authority wanting to establish a new pathology collection centre, renew an existing one, make changes to your current approval, or close down a collection centre. Each separate location requires its own application.

What you'll need

Proof of connection to premises (lease agreement, ownership documents, or rates notice)
Floor plan showing the ACC location, name, address, and area measurements in square metres
Tax payment of $2,000 for 2-year approval (unless co-located with GX or GY laboratory)
Copy of remittance advice if paying by Electronic Funds Transfer

Where to send it

You can submit applications online through Health Professional Online Services (HPOS) at www.servicesaustralia.gov.au/hpos for immediate processing. If unable to use HPOS, complete this form and return it to Services Australia for manual processing as detailed on pages 4 and 5 of the form.

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