Provider Change of Details Form

Change of Details MyHealthCare

Practice Information

Practice name(Required)

Company name(Required)

Company Director or Secretary name(Required)

ABN(Required)

Physical address(Required)

Phone(Required)

Email(Required)

Doctor’s Contact Information

Doctor

Provider No.

Doctor

Provider No.

Doctor

Provider No.

MyHealthCare Champion Information

Practice Manager/s(Required)

Practice Manager Phone(Required)

Practice Manager Email(Required)

Practice Management Software System(Required)

Select Account Preferences

Select Service Fee Schedule(Required)

Freemium $0/month

Select Set Up Fee Owner(Required)

$39 for Patient and $0 for Practice

$0 for Patient and $39 for Practice

Select Payment Dates(Required)

1st of Each Month

1st & 15th of Each Month

Account Holder Information

(Company Director or Company Secretary)

Account Name(Required)

BSB(Required)

Account Number(Required)

Account Holder Identification(Required)

Drivers License or Passport (Maximum File Size 10MB)

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB.

Account Holder Bank Statement(Required)

One statement within last three months (Maximum File Size 10MB)

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB.

Review Terms and Conditions

Direct Debit and Credit Request Acknowledgement

Title(Required)

First name(Required)

Last name(Required)

Signature(Required)

Header Book A Demo

Group 36

Provider Change of Details Form

Change of Details MyHealthCare

Practice Information

Doctor’s Contact Information

MyHealthCare Champion Information

Select Account Preferences

Account Holder Information

Review Terms and Conditions

Direct Debit and Credit Request Acknowledgement