Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Provider Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Provider discipline {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
AHPRA number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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 firstError.message }
Address of this provider number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Suburb {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Postcode {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Fax {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Is this provider number already registered with AHSA? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Is this provider number already registered with BUPA? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Provider's item numbers {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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 }
{ binding firstError.message }
BUPA practice ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Practice Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Need help? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Bank Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Branch {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Account Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
BSB {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Tell us your Specimen Collection Point (SCP) number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Tell us your Location Specific Practice Number (LSPN) number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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 }
{ 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 firstError.message }