1.  Name of provider

2.  Practice/company name

3.  Postal address

4.  Practice/company address

5.  Email address

6.  Practice/company phone number

7.  Practising speciality (eg GP, physio etc)

8.  Medicare provider number (if applicable)

9.  Australian Business Number (ABN)

10. Bank details (MAIB transmit payments by Electronic Funds Transfer (EFT))

To register as a provider, or to amend your current registration details, please complete the following form available for download.

> Provider Application Form [22KB]