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Click ‘Get Form’ to open it in the editor.
Begin by filling out your Practice Details. Enter your Company/Practice Name, Merchant Number, and Terminal Number(s) in the mandatory fields marked with an asterisk.
Provide your Practice Phone, Fax, Email, and Web details in the respective fields.
Next, move to Provider Details. Indicate whether you are adding a new provider or amending an existing one by ticking the appropriate box. Fill in the Title, First Name, Surname, and Provider Number.
Specify your Speciality and provide any required documentation as noted for new providers or amendments.
In the Bank Details section, indicate how this account will be used (HICAPS/Health Fund Payments or EFTPOS Settlement) and fill in the Account Name, Bank Name, BSB, and Account Number.
Finally, ensure all signatories complete their signatures along with their names and positions before submitting the form via fax or email as instructed.

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