Application for a Medicare provider number

and, or prescriber number

for a medical practitioner (HW019)
When to use this form The provider number identifies the location from which a service is
Use this form if you are an eligible medical practitioner and would provided. If you are no longer working at a location, you must close
like to apply for an initial or subsequent Medicare provider number the provider number.
and/or a prescriber number.
Claiming a Medicare benefit
To find out if you are eligible to register, claim or access Medicare
services, go to servicesaustralia.gov.au/hpmedicarebenefits Medicare services claimed must be performed when working
in a private capacity except where the health professional is
www.

employed by, or under contract to, a facility that has been

Applying online using Health Professional Online granted an exemption under subsection 19(2) and/or 19(5) of
Services (HPOS) the Health Insurance Act 1973.
Use HPOS to create subsequent locations when you have an existing
Medicare services must be provided by a private practitioner to
provider number and there are no eligibility restrictions on the
privately billed patients. This means a health professional cannot
locations, for example, government funded entity, registration
provide Medicare services as an employee of a public hospital or
restrictions. HPOS provides a secure and convenient online service
other government funded entity.
for health professionals to streamline interactions with Medicare.
HPOS allows eligible non-restricted health professionals to: Use of residential addresses
• apply for a subsequent location provider number
Careful consideration should be given to using a residential or other
• close and re-open provider locations private address. Provider number location address may be publicly
• update address and contact details available, for example:
• update banking details. • viewable in patient claims history in myGov
To access your records through HPOS, you will need a Provider • included on written referrals
Digital Access (PRODA) account. To register for a PRODA account and • available to private health funds.
find out more about what your health profession can do in HPOS,
go to servicesaustralia.gov.au/hpos
For more information
www.

Recognition Go to servicesaustralia.gov.au/healthprofessionals or call

www.

132 150 Monday to Friday, 8:30 am to 5 pm, Australian Eastern

If recognition is required for access to Medicare as a general Standard Time.
practitioner, specialist or consultant physician, you must also
complete one of the following: Note: Call charges may apply.
Application for Vocational Registration of General Practitioner
(HW060) Filling in this form
• Use black or blue pen.
Application for recognition as a General Practitioner – Fellows
of the Royal Australian College of General Practitioners (HW075) • Print in BLOCK LETTERS.

Application for recognition as a General Practitioner – Fellow of • Where you see a box like this Go to 1 skip to the question
the Australian College of Rural and Remote Medicine (HW076) number shown. You do not need to answer the questions in
between.
Application for recognition as a Specialist or Consultant
Physician (HW077) Note: An application will be returned if information is missing
and/or not signed. Digital or electronic signatures are not
Forms are available at servicesaustralia.gov.au/hpforms
www.

acceptable.
Have you considered applying through HPOS?
Access to Medicare
You must apply for a unique provider number for each place of
practice and profession you practise in.
Provider numbers are allocated to enable eligible health
professionals to:
• provide services listed under the Medicare Benefits Schedule
(MBS)
• refer to relevant specialists and/or consultant physicians, where
eligible
• request certain imaging and pathology services, where eligible.
MCA0HW019 2005

HW019.2005 1 of 5
1 What would you like to apply for? Tick ALL that apply. 5 Languages spoken (other than English)
An initial provider number
A subsequent provider number
Existing provider number Personal contact details
6 Postal address
To re-open a location
Currently closed provider number

Postcode
To close a location
7 Business phone number
Provide details below:
( )
Provider number for location
Mobile phone number

Address for location

Email

Postcode
Residency status
Location end date / /
You must immediately notify Services Australia of any change in
If you are closing, complete questions 1, 2, 3, 6, 7, 31 your residency status.
and 32 only.
8 What is your current residency status?
Prescriber number
Australian citizen
If you are applying for a prescriber number only (you must
Born in Australia Go to 11
already have a provider number allocated) provide details:
or
Provider number
Date you became an Australian citizen
/ / Go to 10
If you do not have a provider number, you must apply for
one to be allocated a prescriber number. or

If you are applying for a prescriber number only, Permanent resident

(and already have a provider number) complete Date you became a permanent resident (if born in Australia
questions 1, 2, 3, 6, 7, 31 and 32 only. provide date of birth).
/ / Go to 10
Applicant’s details or

A provider number will be issued in the name in which you are Temporary Resident Go to 9
registered with the Australian Health Practitioner Regulation
Agency (Ahpra). 9 Are you a New Zealand citizen or New Zealand permanent
resident?
2 Dr Mr Mrs Miss Ms Other No
Family name Yes

First given name Qualification

10 Did you obtain your primary medical qualification in an
Second given name accredited medical school in Australia or New Zealand?
No
Yes For an initial provider number and for any change
3 Your date of birth
in residency status, it is mandatory to supply
/ / evidence of your residency status at your date of
enrolment.
4 Your gender
Provide evidence of your residency status
Male
at your date of enrolment.
Female

HW019.2005 2 of 5
11 Primary medical qualification Recognition
16 Have you applied for recognition as a:
Specialist or consultant physician
Country obtained General practitioner
This information will be used if we need to apply to the
Department of Health for a section 19AB exemption on your
Medical school
behalf.

Required location
Year obtained
17 Are you applying for more than 1 location?
No
12 Did you obtain your base medical qualification from an overseas Where eligible, create subsequent provider
medical college, are subject to the Ten Year Moratorium and Yes
numbers in HPOS or print and provide
require access to Medicare benefits? additional copies of pages 3 and 4 of this
No form, as required. Complete questions 17 to
29 for each additional location.
Yes Provide:
• a copy of your current medical 18 Location start date Location end date (optional)
registration
/ / / /
• personal pages of your passport
• current visa status, and 19 Is this a government funded Aboriginal and Torres Strait Islander
• a letter of support from your employer Health Service or Aboriginal Medical Service?
as to why you require access to
No
Medicare benefits and the period
required. Yes
20 Are you in an approved section 3GA program?
13 Have you signed a Bonded Program agreement with the
No
Department of Health?
Yes
No
Yes Medical Rural Bonded Scholarship (MRBS) Before your application can be finalised, the organisation
authorised to approve your placement must complete and
or
sign an approved placement form and send it to Services
Bonded Medical Places (BMP) Australia. For more information about approved section 3GA
programs, go to health.gov.au
www.

Registration details
21 Location address
14 Ahpra Registration number You must provide address details of a valid address for a
location you are or will be practicing at. Address details must
be completed in full and must not contain ‘corner of’ or
You cannot be allocated a provider number unless you are ‘unknown’ as part of the address. If this is your residential
registered with the Medical Board of Australia. address read the important information on Use of residential
addresses on page 1.
Provide a copy of your current medical registration
certificate if applying for an initial provider number. Practice or hospital name

15 Were you registered with an Australian Medical Board prior to

1 January 1997? Unit Suite Shop Floor number
No Street number Street name
Yes Provide a copy of the medical board
registration from the date of first registration
if not previously supplied. Suburb/Town

State Postcode

Location phone number
( )

Email

HW019.2005 3 of 5
22 Which one of the following do you want to do at this location: 27 Does this practice use Medicare Online?
Tick ONE only No
Refer and request only (such as hospital interns) Go to 30 Yes Give details below
Refer, request and claim Medicare or Department Practice Management Software Location ID
of Veterans’ Affairs rebateable services
Refer, request and assist at private operations only
28 Does this practice use Medicare Easyclaim?
Read this before answering the following questions.
No
Questions 23 to 25 are the details of the person/business/ Yes Give details below
organisation that will receive the Medicare benefit/payment for the
location and the provider number being applied for. Name of the financial institution that supplied the
EFTPOS device
23 Your employment status at this location is:
Tick ONE only
Self Individual proprietor Bank account details
Sole trader
Provide the bank account details for the recipient of Medicare
Joint owner in a partnership
benefit/payment for the location(s) named at question 21.
Employee Salaried
29 Name of bank, building society or credit union
Contracting organisation
24 Business details relating to your employment at this location
Branch number (BSB)
Australian Business Number (ABN) for the person/business/
organisation who will receive the Medicare benefit/payment.
The ABN can be found on ABN lookup abr.business.gov.au
www.

Account number (this may not be the card number)

Australian Business Number (ABN)

Account held in the name(s) of

Australian Company Number (ACN) (If applicable)

Registered (entity) business name

All payments are made through Electronic Funds Transfer
This must match the details as they appear in the entity (EFT). Payments cannot be made via EFT if the nominated
name field on the Australian Business Register. account has restrictions on EFT.
The nominated account for this location will be used for both
Medicare and the Department of Veterans’ Affairs benefit
payments.
25 Business type: Tick ONE only
Individual proprietor
Partnership
Unincorporated association
Company
State Government
Territory Government
Other public body
26 Premises type: Tick ONE only
Hospital - public
Hospital - private
Practice - general practice
Practice - other private practice
Educational institution
Residential care facility
Other community health care service
Home
Mobile

HW019.2005 4 of 5
Checklist Medical Practitioner’s declaration
30 Check you have answered all relevant questions and the form is 32 I declare that:
physically signed and dated. • I am aware of my legal obligation to provide true and
Which of the following documents are you providing with this accurate information.
form? • I have read servicesaustralia.gov.au/hpmedicarebenefits
www.

If you are not sure, check the question to see if you should and understand my legislative requirements on the use of
provide the documents. my Medicare provider number.
• the information I have provided in this form is complete and
Evidence of your residency status at your date of correct.
enrolment.
(if you answered Yes at question 10) I acknowledge that:
• I must notify Medicare of any changes to my residency
A copy of your current medical registration.
status as this change may impact my eligibility to
(if you answered Yes at question 12) access Medicare benefits.
Personal pages of your passport and current visa status. I understand that:
(if you answered Yes at question 12)
• giving false or misleading information is a serious offence
A letter of support from your employer as to why you and that the information I have provided on this form may
require access to Medicare benefits, the practice location be subject to scrutiny through the relevant compliance and
address, and the period required. audit arrangements.
(if you answered Yes at question 12)
Medical Practitioner’s full name
A copy of your current medical registration certificate if
applying for an initial provider number.
A copy of the medical board registration from the date of Medical Practitioner’s signature
first registration.
(if you answered Yes at question 15) On completion, print and sign by hand.
If applying for more than one location, provide a copy of
-
pages 3 and 4 of this form. This must be an original signature. Digital or electronic
(if you answered Yes at question 17) signatures are not acceptable.
For more information about PBS and prescriber numbers, go to www.

Date
servicesaustralia.gov.au/hppbsprescriber
/ / Reset form Print form
For more information about Medicare services, go to www.

servicesaustralia.gov.au/hpmedicarebenefit
Returning your form
Privacy notice Check all required questions are answered and the form is signed
and dated.
31 The privacy and security of your personal information is Your application will be returned to you if all relevant
important to us, and it is protected by law. We need to documentation is not supplied or is incomplete.
collect this information so we can process and manage your Return this form and any supporting documents:
applications and payments, and provide services to you.
• by post to:
We only share your information with other parties where you
Services Australia
have agreed, or where the law allows or requires it. For more
Provider Registration Section
information, go to servicesaustralia.gov.au/privacy
GPO Box 9822
www.

in your capital city

• by fax to:
NSW/ACT 02 9895 3439 SA/Tas 08 8274 9307
Vic/NT 03 9605 7984 WA 08 9214 8201
Qld 07 3004 5634

HW019.2005 5 of 5