Registration Form for Doctors

For Doctors

1. Medical provider information

* Required field

First name *

Last name *

Australian business number (ABN) *

AHPRA number *

Provider speciality *

Phone number *

Email address *

Country *

Postal address *

City/Town *

Province/State *

ZIP/Postal code *

Gap payment option *

No GapKnown Gap

2. Practice information

You may add multiple practices you want to register.

Practice details 1

Provider number *

Provider number registered with health funds? *

YesNo

Practice name *

Country *

Practice address *

City/Town *

Province/State *

ZIP/Postal code *

Practice phone *

Practice email *

Upload Medicare provider number letter *

PDF, JPG, PNG or DOC. Max 5 MB.

3. Banking information

Account holder name *

Financial institution *

Branch *

BSB no. *

Account no. *

Upload proof of bank account *

PDF, JPG, PNG or DOC. Max 5 MB.

4. Authorisation

I hereby agree to engage Advanced Medical Billing Services Pty Ltd to process medical billing claims on my behalf. *

I agree as part of this service that Advanced Medical Billing Services Pty Ltd will be entitled to 4% (plus GST) of the total paid claims amount calculated on a fortnightly basis. At the end of the financial year, Advanced Medical Billing Services Pty Ltd will provide a cashback if total billings for the financial year have achieved a minimum amount of $300,000 and the cashback will be 1% (plus GST) of the total paid claims amount. If total billings for the financial year reaches a minimum amount of $550,000, the cashback will be 1.5% (plus GST) of the total paid claims amount. *