1. No category

Banking Details
Online Claiming
When to use this form
Location identifier
Use this form to provide your banking details for online claiming.
This form should only be completed by the Payee Provider of the
practice. If you are the payee provider for more than one location you
must complete a separate form for each practice’s Location ID (minor
ID).
1 Location ID (minor ID)
Any provider not yet registered for online claiming will need to
complete the Online Claiming Agreement. To access the agreement
go to humanservices.gov.au/healthprofessionals and search for
Online Claiming Provider Agreement.
For more information
For more information about Online Claiming visit our website
humanservices.gov.au/healthprofessionals and search for
Online claiming or email the eBusiness Service Centre in your state
or territory or call 1800 700 199 (call charges from mobile phones)
Monday to Friday, between 8.00 am and 7.00 pm, Australian Eastern
Standard Time.
• VIC/TAS email: [email protected]
• NSW email: [email protected]
• QLD email: [email protected]
• WA/SA/NT email: [email protected]
Practice details
2 Practice name
3 Address
Postcode
Postal address (if different from above)
Filling in this form
Please use black or blue pen.
Postcode
Mark boxes like this  or .
4 Contact name
Go to 5 skip to the question
Where you see a box like this
number shown. You do not need to answer the questions in-between.
5 Phone
Returning your form
Check that you have answered all the questions you need to answer
and that you have signed and dated this form.
Fax
( )
Return this form to:
Email
eBusiness Service Centre
Department of Human Services
GPO Box 9822
@
in your capital city
Corporate details
or fax to the eBusiness Service Centre in your state:
NSW 02 9895 3190
ACT 02 9895 3190
VIC 03 9605 7981
TAS 03 9605 7981
SA 08 9214 8173
NT 08 9214 8173
WA 08 9214 8173
QLD 07 3004 5526
6 If your practice is part of a corporate group with two or more
practices, please provide corporate details.
Banner group name
Corporate name
Privacy notice
Centrelink, Medicare Australia, Child Support and CRS Australia are
all part of the Australian Government Department of Human Services
(Human Services). Personal information held by Human Services is
protected by law, including the Privacy Act 1988. The information on
this form will be used for the purpose of making electronic payment
of claims to you. The collection of this information is authorised by the
Health Insurance Act 1973. Your bank account details may be disclosed
to the relevant financial institutions to facilitate your request, the
Department of Health and Ageing, or as authorised or required by law.
2060–L.1205
Corporate address
Postcode
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Person 2
Name
Corporate contact name
Phone
Provider number
Fax
( )
Provider’s signature
Email
Person 3
Name
@
Bank details
Provider number
You must complete a separate form for each account that you want
Electronic Funds Transfer (EFT) payments to.
7 The following account details are to be used for the providers
listed below, effective from
/
Provider’s signature
-
/
8 Name of bank, building society or credit union
Person 4
Name
9 Branch where account is held
Provider number
10 Branch number (BSB)
Provider’s signature
11 Account number
Person 5
Name
12 Account held in the name(s) of
Provider number
13 What type of online transactions do you want paid to this
account?
Medicare Bulk Bill /Department of Veteran Affairs claims
Australian Childhood Immunisation Register claims
Provider’s signature
-
Payee provider details
14 I undertake to immediately notify my Pay Group(s) or Third Party
Person 6
Name
payee(s) of any current and/or future Notice(s) issued on Human
Services to garnish or intercept payments due to me or my
provider number(s).
Person 1
Name
Provider number
Provider’s signature
-
Provider number
Provider’s signature
Reset form
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