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:
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

I hereby declare that the information is true and correct and approve direct credit payments to be made in accordance with this information.
Authorised by:
Date: