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Home
About Us
Products
Provider Network
- Join Our Network
- Find A Provider
Contact Us
- FAQs
Blog

Home
About Us
Products
Provider Network
- Join Our Network
- Find A Provider
Contact Us
- FAQs
Blog

Become a Provider: OpticalleadwayDev2023-08-02T10:36:49+01:00

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Practice Name

Address

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Branch Address

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Branch Address

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Branch Address

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Local Government

Add Another branch

Branch Address

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State

Local Government

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Branch Address

Suburb/Town

State

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Hospital Phone Line 1

Hospital Phone Line 2

Email for portal access

Name of Managing Director

Name of Primary Contact Person

Name of Secondary Person

Email of Managing Director

Mobile No. of Primary Contact Person

Mobile No. of Secondary Person

Facility available days & time

Open From

Bank Account Name

Bank Name

Bank Account Number

Claims Payment Frequency

Number of Optical Rooms

Available Specialists

please select the days that apply

Ophthalmologist

Monday

Tuesday

Wednesday

Thursday

Friday

Sat/Sun

Optometrist

Monday

Tuesday

Wednesday

Thursday

Friday

Sat/Sun

Other Ophthalmology sub-specialization

Monday

Tuesday

Wednesday

Thursday

Friday

Sat/Sun

Copy of CAC registration certificate

Copy of Evidence of Registration with the relevant state accreditation agency

Copy of Certificate of Medical Indemnity Insurance as detailed under section 8 of the agreement

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