ARHG


www.arhg.com.au
ABN: 44 067 435 714

ARHG Medical Gap Cover Scheme

Provider Registration Form

Section A - Medical provider details

Provider Firstname:
Provider Surname:
Provider speciality:
Please list all provider numbers this registration applies to:
+
Mailing address:
Suburb:
State:
Postcode:
Note: must be medical specialist's phone number, not billing agent.
Note: must be medical specialist's email address, not billing agent.
Phone: (example 0355555555)
Email:

Section B - Billing Agent details (if applicable)

Name of Billing Agent:
Address of Billing Agent:
Suburb:
State:
Postcode:
Contact person for billing enquiries:
Email address for remittance advice:
Telephone number: (example 0355555555)
Mobile number: (example 0415555555)

Section C - Bank Details

Name of Financial Institute:
Account name:
BSB:
-
Account number:

Section D - Health Fund Registration

Register me with the following private health insurers (please tick the relevant box/es):
Cessnock District Health Fund
Cessnock District Health Fund Cover arrangements
LaTrobe Health Services
Latrobe Health Services Cover arrangements
Mildura Health Fund
medical@mildurahealthfund.com.au
St. Lukes Health
St. Lukes Health Cover arrangements

Section E - Declaration

By submitting this registration form, I declare that:
I am the medical specialist OR I am authorised to act on behalf of the medical specialist to register and update their information with ARHG and ARHG Member Funds.
The information is true and correct and I approve direct credit payments to be made in accordance with this information.
The bank details supplied are authorised for the purpose of allowing Funds to electronically transfer monies directly into that account, being in payment of claims submitted (even if they are in another person's name).
I have read and understand the Medical Provider Registration Process
I have read and understand ARHG's Privacy Policy
Authorised by:
Date: