¥ Austra | twoitensee Application for an additional location Medicare medicare provider number for a medical practitioner Personal details Registration details 1 Quote an existing Medicare provider number © State ortenitoy i i i ceeeaaaaeasee) Registration number 2 of me mrs) iss ms otter MIE [D010 of fA S560 (aura foo TT [tis application for more an oe sate orteritny: | First given name ‘State or territory (RATHI L_____ seen pepe eae {ou cannot be lost a prover rumba uss you ave oD LOA 1484 Personal contact details | medical board registration in the state or teritory in which Residency status 7 tyau obtained your primary medical qualification in an accredited medical school in Australia or New Zealand, what was your residency status when you enrolled: ‘Astralianclizen or permanent resient(2 ‘New Zealand citizen or New Zealand permanent resident [_] Temporary resident [] Has your residency status changed since you last aplied fora Provider number? NOD Go to 14 ves ave you become an Australian citizen? no LJ Yes CD date granted 5 Doyou want these detalls recorded as your preferred contact details? wo ves ST 0821508 former 1413) 5o0t7 (ae) Date granted (1 1 Down ‘ie you a New Zealand citizen or New Zealand permanent resident? noes ves‘if applying for more than one location, you must complete | questions 12-17 for each locaton by attaching a separate sheet ee _ 12 Location startdate 10S /02/ 2017} Location ond date 06/05/2017) atknown) 13 Which one ofthe following do you want to do at ths location: ‘refer and request ony (e.g. hospital interns) no ves 64 or ‘fer, request and provide Medicare rebateable services, No ves bal or refer, request and assist at operations only no ves ‘The required location must be the physical address (nota post office box from which you wil ender services. 16and 17. 14 Practice name or building SANDRINGHAM Hosp TAL 16 Does this practice use Medicare Easyctaim? No. ves [which financial insttution supplies the EFTPOS device? 17 ‘is this a government funded Aboriginal and Tors Strat Slander neatth service? No ves Bank account details for the location | Al payments are made trough Electronic Funds Transfer (EFM). | Payments cannot be made via EFT ifthe nominated account as | [Ltesirctlons on EFT depoots, 18 Name of bank, building society or credit union Branch where the account is held ‘Branch number (BSB) ‘Account number (this may not be the card number) Property or Department EMERGENC] DEPARTMENT Unit Suite ‘Shop| Floor number Specialist recognition Street number \ ‘Street name BLUEE ROAD ‘Suburb SANDRINGHAM state[ VIC] Posteode [314 1 Business phone number (03) 1OFG |OCO Fax number (03) 4046 14 9h Email, 1. 9050, salted 6% 15 Does this practice use Mecicare Online? Wo Yes LD wnat s the Practice Management Software Location 10? ‘62.1508 rary 1418) ‘racttone, specialist or consultant physician, you must compete an | ‘dcitonal form (refer to ‘Aditional documents on pages 2 and 3}. | eee me ee 19 Have you applied for recognition asa: ‘Specialist or consultant physician Genera practitioner [_] Closing locations ‘Sasso the information below. You can attach a list you wish to close ‘more than one location, 20 Provider number a “T 6of7Privacy notice 21 Your personal information is protected by law, including the Privacy Act 1968, and is colected by the Australian Govemment Department of Human Services for the assessment and ‘administration of payments and services. This information is ‘Fequired to process your application or claim. Your information may be used by the department or given to other partes for the purposes of research, investigation or wihere you have agreed or ti required or authorised by law. You can get more information about the way in wich the Department of Human Services will manage your personal {information including our privacy policy at ‘humanservices.gov.aw/privacy or by requesting a copy from the department. Declaration 22 I dectare that: ‘+ the information | have provided inthis form is complete and ‘correct. understand that: "© giving false or misleading information is a serious offence. Provider's full name ae _____ TH OSAV) Provider's & dl Date OF 1 0% 201}, tae 108 fomary 1415) Tot7