Legal name \ Entity \ Organisation (If you are a sole trader, enter your full name.) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Trading name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

ABN {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Postal / Zip Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Country {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Postal Address

Same as above? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Postal / Zip Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Main Contact

First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mobile {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Accounts Contact

Accounts Contact (Whom should we send invoices to?) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Accounts Contact Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mobile {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

General Questions

Describe further {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How did you hear about us? If you were referred by an existing ACSS user, please let us know who, so that we can offer him or her a small token of our gratitude. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Anything further you wish to let us know about? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Provider Details

Provider Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Provider discipline {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

AHPRA number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

You can search for it here if you are unsure: https://www.ahpra.gov.au/registration/registers-of-practitioners.aspx

List all provider numbers you wish us to bill on your behalf.

Provider Number {binding ItemNumber}

Provider Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address of this provider number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Suburb {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Postcode {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Fax {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Provider's item numbers {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Does the provider work in hospital? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Tell us the hospital name and hospital provider number. This should not be the provider's provider number. E.g., The Mater 0015790H {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Does the provider need to send in-hospital claims to the health funds? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is the provider registered with the Alliance group (AHSA)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does the provider have a Gap or prefer to bill as No Gap? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is the provider registered with Medibank / AHM? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does the provider have a Gap or prefer to bill as No Gap? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is the provider registered with BUPA? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does the provider have a Gap or prefer to bill as No Gap? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

BUPA practice ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Practice Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is the provider registered with HCF? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does the provider have a Gap or prefer to bill as No Gap? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is the provider registered with NIB? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does the provider have a Gap or prefer to bill as No Gap? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Need help? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Would you like MYNT to register you for ECLIPSE with all the health funds? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Bank Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Branch {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Account Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

BSB {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does the provider need to send claims to Medicare or DVA also? If you answer yes, we will need to get the provider to complete some Medicare paperwork. This Medicare paperwork is not required if only sending claims to the health funds. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is the provider's billing mix? Claims sent: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does the provider plan to send pathology services? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Tell us your Specimen Collection Point (SCP) number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does the provider plan to send radiology/imaging/diagnostic services? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Tell us your Location Specific Practice Number (LSPN) number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Provider's referring doctors. Send us the first name, surname and provider number (Only if you wish, not required/essential) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If you have a list of your referring doctors details in excel (excel only), attach it and we can import that list into your eClaims. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}