Fillable Application for registration to provide services to workers (Department of Infrastructure, Transport, Cities and Regional Development)

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Application for registration to provide services to workers (Department of Infrastructure, Transport, Cities and Regional Development)

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The Application for registration to provide services to workers (Department of Infrastructure, Transport, Cities and Regional Development) form is 5 pages long and contains:

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  • 37 check-boxes
  • 45 other fields

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FOR833/08/12.20
General information and instructions
Who should complete this form?
This form should be used by health professionals and personal and household support service providers (eg. household
help, remedial exercise) who wish to become registered with WorkSafe Victoria (WorkSafe) to provide services to
injured workers. To determine whether you need to complete this form, please refer to the WorkSafe Victoria Provider
Registration Requirements at worksafe.vic.gov.au
How to complete your application:
Refer to the WorkSafe Victoria Provider Registration Requirements for the service you are applying for at
worksafe.vic.gov.au
to find out what information must accompany this form.
Fill in the relevant sections of this form.
Attach documents required to support your application.
Include any extra information (eg. other location details) on a separate sheet and attach.
Sign the provider declaration and consent on page 5 (section 8).
Please complete your application and return via email, alternatively to the postal address address/fax number
listed below:
Email: service_provider_registration@worksafe.vic.gov.au
Post: WorkSafe Victoria
Provider Registration Unit
PO Box 279
Geelong VIC 3220
Fax no: 03 9641 1767
If you need further information:
Website: worksafe.vic.gov.au
(refer to WorkSafe Victoria Provider Registration Requirements)
Phone: 03 9641 1444
1800 136 089
Acupuncture: Chinese
medicine practitioners
Booking service provider
Chiropractic
Dental
Dietitian
Exercise physiology
Hearing services – audiometry
Hearing services – audiology
Household help – domestic cleaning
Household help – gardening
Loss and grief counselling
Medical
Naturopathy
Nursing
Occupational therapy
Optometry
Orthotist
Osteopathy
Pharmacy
Physiotherapy
Podiatry
Professional interpreting
services
Prosthetist
Psychology
Public Ambulance
Private Ambulance
NEPT – Non Emergency
Patient Transport
Remedial exercise – gym
Remedial exercise - pool
Remedial massage
Social work
Speech pathology
1. Application type
I wish to apply to provide the following service:
Application for registration to provide
services to workers
2
2. Applicant details - individual
Please complete section 2 if you are applying as an individual (only applicable for medical and allied health
providers)
Title Given name Surname
Practice address (actual street address) - include business name
Postcode
Telephone Mobile
Email (to be used for both correspondence and e-remittance)
Board/professional association name Registration number
Practice start date
Medicare provider number
(where applicable)
Medibank provider number
(
where applicable)
Additional practice details
Practice address (actual street address) - include business name
Postcode Practice telephone
Practice start date
Medicare provider number
(where applicable)
Medibank provider number
(where applicable)
For any further sites please provide these details on a separate sheet and attach to your application.
Please sign the Consent and Declaration at 8a on page 5.
3. Applicant details - business/company
Please complete section 3 if you are applying as a business/company (where applicable for home help
- domestic cleaning & gardening, nursing, remedial exercise - gyms & swimming programs, interpreting)
Business/company name ABN/ACN
Trading name (if dierent from business/company name)
Business/company address (actual street address)
Postcode
2
33
5. Banking details - Please complete this section if you would like to be paid by Electronic Funds Transfer
Account name - please insert exact name the account is held in
BSB (must be six digits) Account number
By selecting to receive payments via EFT you also agree to receive remittances in an
electronic format (email). For providers with multiple practice locations that have dierent
EFT details, please attach these using the Electronic Funds Transfer Application
Form.
This request to deposit funds directly into the account described in this section is valid
until further notice. If at any time the account details change for any reason then please
complete the Electronic Funds Transfer Application Form.
Frequency of payment
Payments are processed daily. This may result in
receiving one remittance for payments made
each day (per Agent)
Tick this box if you would prefer to receive
weekly payments and remittances
4. Preferred postal address
Mail and cheques will be forwarded to this address instead of the practice/business address
Postcode
Contact name Position
Telephone Mobile
Email (to be used for both correspondence and e-remittance)
Start date (where applicable)
Please sign the consent and declaration at 8b on page 5.
6. Collection of personal information
Personal information collected by WorkSafe Victoria (WorkSafe) may be used to register you as a Provider, to verify that you meet WorkSafe’s
eligibility requirements and business standards (such as being a registered business and holding the requisite insurance coverage), to ascertain
the veracity of information provided by you and to enable payments to be made to you. If you do not provide all of the information WorkSafe
requires, you may not be registered with WorkSafe as a Provider or paid.
Personal information collected by WorkSafe may also be used for other related purposes, including administration and evaluation of WorkSafe’s
programs, to assist WorkSafe and its authorised agents (WorkSafe Agents) to manage individual worker claims and to better manage claims
generally, and for the purposes of legal proceedings. WorkSafe may make information about registered service providers publicly available.
WorkSafe may publish this information on the WorkSafe website. You may request information about your registration status not be published by
sending a written request to the Director, Health Operations Division.
WorkSafe may disclose any personal information it collects to its WorkSafe Agents, legal practitioners, contractors, consultants and other service
providers engaged by it or by its WorkSafe Agents, to the Accident Compensation Conciliation Service, to courts or tribunals and to any person or
organisation authorised by you, or by law, to obtain it.
WorkSafe’s policies for managing personal information are set out in its Privacy Policy, which is available from your nearest WorkSafe oce or on
the WorkSafe website at worksafe.vic.gov.au
44
7. Provider registration requirement
Objectives
1. It is a requirement of registration with WorkSafe as a provider of
services that the Provider complies with WorkSafe’s registration
requirements as set out in this application and the WorkSafe Victoria
Provider Registration Requirements at worksafe.vic.gov.au
Definitions
2. “Provider” means a provider of services and includes a body
corporate, sole trader or a partnership as registered with WorkSafe in
accordance with Victorian workers compensation legislation (the
legislation).
3. “Services” means services to or for workers approved by WorkSafe
and for which the reasonable costs of such services are payable by
WorkSafe and WorkSafe Agents as compensation to workers with an
accepted claim for a work-related injury or illness in accordance with
the legislation.
Insurance
4. The Provider must maintain at all times insurance coverage
appropriate to the level of risk of the services they provide.
Minimum requirements for certain providers are detailed in the
WorkSafe Victoria Provider Registration Requirements at
worksafe.vic.gov.au
5. For those services with minimum requirements, Providers must
immediately notify WorkSafe should the Provider cease to have the
required insurance(s). The Provider acknowledges that cessation of
insurance(s) may result in WorkSafe registration as a Provider being
withdrawn.
Confidentiality and privacy
6. The Provider and its sta must respect the confidentiality of workers
at all times.
7. The Provider acknowledges that it is an oence to use information
obtained under or pursuant to the legislation except as authorised.
8. The Provider must comply with the obligations imposed under the
Information Privacy Act 2000 and the Health Records Act 2001 and
such reasonable policies or directions relating to the collection, use,
disclosure, storage, transfer or handling of personal or health
information of workers as are notified by WorkSafe to the Provider from
time to time.
Standard of provider facilities
9. The Provider must comply with all relevant occupational health and
safety laws, including for Victorian workplaces, the Occupational
Health and Safety Act 2004 and Regulations.
10. The Provider must provide a fully equipped and easily accessible
first aid kit in a prominent location of the facility and ensure that all sta
members know its location and are appropriately qualified in its use.
11. The Provider must ensure that all equipment used or proposed to be
used by a worker:
a. is mechanically sound, and is installed and operated in accordance
with the manufacturer’s instructions and standards; and
b. is serviced as required to ensure continued user safety.
12. The Provider must ensure that the Provider and its sta can
adequately instruct workers in the safe and proper use of equipment.
13. The Provider must ensure that all areas used to provide services to
workers have adequate safe working space and that user numbers do
not hinder the safe and eective use of equipment.
14. The Provider must ensure that all wet areas used by workers are
cleaned frequently and regularly in order to maintain a high standard of
safety.
Assessment criteria
15. The Provider and all relevant sta (as applicable) must satisfy the
relevant WorkSafe provider requirements as specified in the WorkSafe
Victoria Provider Registration Requirements on WorkSafe’s website at
worksafe.vic.gov.au
Remuneration and billing
16. Invoices of the Provider must be accurate and capable of being
substantiated by WorkSafe or WorkSafe Agents on demand.
17. Invoices must be submitted by the Provider in a manner consistent
with established billing processes as advised by WorkSafe or its
WorkSafe Agents from time to time.
18. The Provider acknowledges that WorkSafe and WorkSafe Agents
are liable only for payment of the reasonable costs of services provided
to workers with accepted compensation claims for work-related
injuries or illnesses in accordance with the legislation, which may not
mean the full costs of the service. The Provider must clearly advise a
worker of, and seek agreement from the worker for, any gap between
what the Provider charges for services and what WorkSafe can pay as
the reasonable costs of the services.
19. Services paid to the provider must be able to be supported by
clinical records, case notes and/or attendance records.
20. The provider may be required to undergo an audit of payments
made to him/her for services provided to injured workers as part of
WorkSafe’s Billing Review Program at any time.
Provider Conduct
21. The Provider must not submit invoices for services not directly
related to a worker’s work-related injury or illness. The Provider
acknowledges that it is an oence to obtain or attempt to obtain
fraudulently any payment or to provide false or misleading information
under the legislation.
22. The Provider must maintain at all times the applicable Board
registration or eligibility for professional association membership for
the services they are registered to provide, as detailed in the WorkSafe
Victoria Provider Registration Requirements on WorkSafe’s website at
worksafe.vic.gov.au
23. Providers must immediately notify WorkSafe should they cease to
have the applicable Board registration or eligibility for Professional
Association membership. The Provider acknowledges cessation of
Board registration or eligibility for Professional Association membership
may result in WorkSafe registration as a Provider being withdrawn.
24. The Provider acknowledges that should:
a. the Provider fail to comply with any part of the Provider
Registration Requirements;
b. WorkSafe reasonably suspect that an oence against Victorian
workers compensation legislation or the Crimes Act 1958 in connection
with a worker’s claim for compensation has been committed or the
Provider be convicted or found guilty by a court of such an oence;
and/or
c. WorkSafe be concerned about the adequacy, appropriateness or
frequency of any services provided.
55
b) Please complete section 8b if you are applying as a business/company
Business/company name
Signature of authorised representative
Date
Position held by authorised representative
FOR833/08/12.20
WorkSafe Victoria is a trading name of the Victorian WorkCover Authority
8. Consent and declaration by applicant
The Provider agrees to be bound by the provider registration requirements detailed on this form and as specified in the
WorkSafe Victoria Provider Registration Requirements at worksafe.vic.gov.au
The Provider consents to the collection, use and disclosure of personal information by WorkSafe for the purpose
outlined in the section headed ‘Collection of Personal Information’ on this form.
The Provider agrees to provide services in accordance with relevant WorkSafe policies and guidelines.
By signing this form, I declare that all the information provided is true and correct.
a) Please complete section 8a if you are applying as an individual
Full name
Business name (where applicable)
Signature Date
WorkSafe may as appropriate and in accordance with the legislation:
• suspend or deny payment for services or seek recovery of
payments made to the Provider for services as a debt or set o;
• notify the Provider’s regulating body or responsible board, self-
insurers, Medicare Australia, a court or tribunal and/or the Authority,
Committee, Director or Panel within the meaning of the Health
Insurance Act 1973 of the Commonwealth;
• suspend or withdraw the Provider’s registration; and/or
• cause the outcome of any determination of WorkSafe or order of the
court to be published, together with the name and business address
of the Provider of the services to which the determination or order
applies.
25. The Provider agrees there will be no claim for damages as a result
of any of the actions of WorkSafe as described in the preceding
paragraph.
No guarantee of referrals
26. The Provider acknowledges that registration with WorkSafe as a
Provider of services to workers under the legislation in no way
guarantees any worker patronage or use of the Provider’s services or
referral of any worker to the Provider by WorkSafe or WorkSafe
Agents.
Maintaining your registration
27. At all times you will have to comply with the current WorkSafe
Victoria policy, as outlined on our website.
28. Please make sure that any changes in your organisational details
such as address, phone number are communicated to us as soon as
possible.
29. WorkSafe Victoria reserves the right to cease a provider number if
the Authority is unable to contact you (either by mail, email or phone).
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Application for registration to provide services to workers (Department of Infrastructure, Transport, Cities and Regional Development)

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Completed 15 September 2021

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