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HCF Application for Provider Recognition

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HCF                             Application for Provider Recognition
 Please complete a separate form for additional professions or practices for which you seek recognition.


Title ___________ First Name ______________________________________                                                                                  Allied Health Professionals
Family Name ____________________________________________________                                                                                      Dentist
                                                                                                                                                           General Dentist                      Pedodontist
Have you registered as a provider with HCF before?                                                              Yes/No
                                                                                                                                                             Endodontist                        Periodontist
                                                                                                                                                             Hygienist                          Prosthetist
Health professionals who are not registered with a board must
belong to a professional association that forms part of the HCF                                                                                              Oral Surgeon                       Prosthodontist
Group recognition criteria. Please provide the name of your                                                                                                  Orthodontist
association or board and membership number:
                             Association/Board                                                          Membership No.                                       Audiologist
____________________________________                                                      _________________________                                          Chiropractor
____________________________________                                                      _________________________                                          Dietician

____________________________________                                                      _________________________                                          Exercise Physiologist              Physiotherapist
                                                                                                                                                             Osteopath                          Podiatrist
Private Practice 1 (Allied Health Professionals other than Dental Hygienist must provide Medicare Provider Number)
                                                                                                                                                             Occupational Therapist             Psychologist
Medicare Provider Number ______________________________________                                                                                              Speech Pathologist
Practice name __________________________________________________
Address _________________________________________________________                                                                                    Optical Service Providers
Suburb ___________________ State _____________ Postcode _________
                                                                                                                                                              Optometrist                       Orthoptist
Telephone Number ___________________________
Private Practice 2                                                                                                                                   Acupuncturist and Chinese Herbal Medicine
                                                                                                                                                     Providers from the state of Victoria
Medicare Provider Number ______________________________________
                                                                                                                                                              Acupuncture                       CHM
Practice name __________________________________________________                                                                                      Please, check our website for more details.
Address _________________________________________________________                                                                                     Health Management Program Providers
                                                                                                                                                      Providers of Heath Management Programs only
Suburb ___________________ State _____________ Postcode _________                                                                                     complete practice name, address and contact details
                                                                                                                                                      of this form.
Telephone Number ___________________________
                                                                                                                                                         Quit Smoking         -by registered psychologist

If mailing address is different from above, please provide details below                                                                                 Stress Management           -by registered psychologist

                                                                                                                                                         Weight Management
_________________________________________________________________
                                                                                                                                                         Cardiac Rehabilitation
_________________________________________________________________                                                                                          In support of your application for any of the above,
                                                                                                                                                           please supply
Declaration                                                                                                                                                    -Professional qualifications of facilitators
I certify that the information I have supplied is correct. I understand that as an                                                                             -Senior First Aid
HCF Group recognised provider, providing services to HCF Group members I                                                                                       -Indemnity insurance
will be subject to Terms and Conditions for HCF Group Recognised Providers of
                                                                                                                                                         Childbirth Education        -by registered midwife or nurse
General Treatment ("The Terms") and the HCF De-listing Policy which I have
viewed on www.hcf.com.au/therapist.                                                                                                                      Asthma Education and Management
                                                                                                                                                          -send copy of Asthma Education certificate
The Terms and The De-listing Policy may change from time to time; up to date versions are available on www.hcf.com.au or by calling 02 9290 0158.
                                                                                                                                                         Diabetes Education and Management                  -send copy
                                                                                                                                                          of Diabetes Education diploma or ADEA accreditation

Signature ____________________________________                                                                                                           First Aid       -must be Work Cover or VETAB accredited

                                                                                                                                                         Learn to Swim        -send copy of AUSWIM or Swim Australia
Date ________________________________________
                                                                                                                                                    Certificate.


Please make sure that you have completed all sections and attached required documents before mailing to
Provider Relations, GPO Box 4242, Sydney 2001 or fax to (02) 9279 3549. You can call us on (02) 9290 0158.
                                                                                                Commercial in Confidence

				
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Description: HCF Application for Provider Recognition