Get Add Amend Provider Form

This guide provides step-by-step instructions on how to complete the Add Amend Provider Form online. By following these guidelines, you can ensure that your application is filled out correctly and submitted without issues.

Follow the steps to complete the Add Amend Provider Form online

1. Click the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin with section A, where you will need to enter your Practice Details. Mandatory fields include your Company/Practice Name, Merchant Number, and Terminal Number(s). Additionally, provide the Practice Phone and optional fields such as Practice Fax, Email, and Website.
3. Next, move to section B for Provider Details. Here, fill in the Title, First Name, Surname, and Provider Number. Indicate whether you are adding a new provider or amending an existing one. If applicable, provide the Speciality and the relevant Australian Association Name along with the Association Membership Number.
4. In section C, you will need to fill out your Bank Details. Specify the purpose of the account by ticking the relevant boxes for HICAPS/Health Fund Payments and/or EFTPOS Settlement. Enter the Account Name, Bank Name, BSB, and Account Number as required.
5. Finally, proceed to section D, where all authorized signatories must add their signatures. Each signatory will need to provide their Name, select their Position (Director, Partner, Sole Trader), and date the form. Ensure all signatories of the original HICAPS/EFTPOS contracts have included their signatures.
6. Once all sections are completed, review the form for accuracy. Save any changes you made, then download, print, or share the completed form as needed. Email it to providerservices@hicaps.com.au, fax it to 1300 725 726, or mail it to GPO Box 84A, Melbourne Vic 3001.

We encourage you to complete your Add Amend Provider Form online for a streamlined experience.