POAC Provider Registration Form
Type of notification:
*
New provider or practice
Change of ownership or name
Change of bank details only
Provider type:
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General Practice / Urgent Care
Aged Care Provider
Radiology
Pharmacy
Other
Effective as of the following date:
*
-
Day
-
Month
Year
Date
Organisation Name
*
Previous Name
HPI Facility Code
*
where applicable
Contact Person
*
First Name
Last Name
Contact Email
*
Address
*
City
Post Code
Phone number
*
PHO Affiliation
*
Auckland PHO
Comprehensive Care
East Health Trust
National Hauora Coalition
Procare Health
The Cause Collective
Total Healthcare
N/A
where applicable
Practice GP names and NZMC #
Practice Management System In Use
Indici
Medtech 32
Medtech Evolution
MyPractice
Profile
Other
Account Information
Accounts Email
*
for receiving payment advice
GST Number
*
Bank account name
*
Bank account number
*
For General Practice payments, are payments required to be paid to practice or individual GPs?
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All to practice account
All to individual GP
Combination of the above
Attached bank generated/verified deposit slip that shows your full account details (name of account and full bank account number with suffix).
*
Browse Files
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Additional comments
Submit
Invoices for POAC services should be made out to East Health Services Limited
The supplier will provide East Health Services Ltd with a fully conforming tax invoice for all goods or services supplied.
East Health Services Ltd will pay the invoice within the month following month in which the invoice is received.
East Health Services Ltd recognises the importance of keeping this information private and confidential. This information will not be distributed other than to those required to use this information for administration purposes within the organisation.
Should be Empty: