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Practice Name

Address

State

Local Government

Suburb/Town

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Branch Address

Suburb/Town

State

Local Government

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Branch Address

Suburb/Town

State

Local Government

Add Another branch

Branch Address

Suburb/Town

State

Local Government

Add Another branch

Branch Address

Suburb/Town

State

Local Government

Add Another branch

Branch Address

Suburb/Town

State

Local Government

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

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

Upload Practice Licenses of Professional Staff

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