Please select your request type*
Section 1: Provider Details
Title Date of Birth
Provider First Name* Provider Middle Name
Provider Last Name*
AHPRA Registration Number*
Check AHPRA Registration Number
here.
ABN
Professional Contact Details
Email*
Area Code* Phone Number*
In providing us with your professional contact email address, you agree to receiving general correspondence from Medibank Private
Limited and ahm Health Insurance related to company processes and the Private Health Insurance sector. To read our privacy policy and
find out more about how we handle your personal information visit
www.medibank.com.au
.
Section 2: EFT and Billing Details
EFT Details
BSB Number* - Account Number*
Account Name*
Billing Details
First Name
Last Name
Address Line 1*
Address Line 2
Suburb*
State* Post Code*
Email*
Area Code* Phone Number*
Please note: EFT and Billing Details will apply to the Medicare registered provider numbers specified under Section 4.
In providing us with your billing email address, you agree to Medibank Private Limited and ahm Health Insurance sending remittance advices and
benefit statements by email. To read our privacy policy and find out more about how we handle your personal information visit
www.medibank.com.au.
Section 3: Authorisation
I declare that, by completing this application form, I am agreeing to the terms and conditions of the GapCover scheme which can be found here. I
authorise Medibank Private Limited and ahm Health Insurance to keep a record of the above account details and to use them for the purpose of
allowing electronic funds transfers directly to the nominated account to effect the payment of claims for eligible members. Neither Medibank
Private Limited nor ahm Health Insurance accepts responsibility for payment if the account details provided are incorrect. For any changes to
account details, a minimum of 14 days’ written notice is required.
I do not consent to be published as a GapCover Provider.
Unless you check the above box, we assume you consent to be published as a GapCover Provider for Medibank Private Limited and ahm Health
Insurance, which will include your title and name in Section 1, Medicare registered addresses of the provider numbers and your phone numbers
specified in Section 4 of this form.
Name of Authorised Person*
Position of Authorised Person*
By checking this box, I confirm that I have the authority to submit this form. *
Date*
Please refer to Section 4 for GapCover Participating Locations.
