Provider Information Form

Type of notification:*

New Organisation - Provider or PracticeChange of ownership or nameChange of bank details only

Provider type:*

Effective as of the following date:*

Date

Organisation Name*

Previous Name*

HPI Facility Code*

where applicable

NZBN

Contact Person*

First NameLast Name

Contact Email*

Address*

City

Post Code

Phone number*

PHO Affiliation*

where applicable

Practice GP names and NZMC #

Practice Management System In Use

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?*

All to practice accountAll to individual GPCombination 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). *

Additional comments

Claims can be submitted via the POAC claiming system within the Practice Management System.
For suppliers without access to this system, a fully compliant tax invoice must be provided to East Health Services Ltd, detailing:

Patient name
NHI
POAC case number
Date of service
Service(s) provided

East Health Services Ltd will make payment within the month following receipt and approval of the invoice or claim.

Any further queries can be directed to accounts@poac.co.nz

East Health Services Ltd is committed to maintaining the privacy and confidentiality of all information received. Information will only be shared with personnel who require access for administrative purposes within the organisation.

POAC Provider Information Form

Account Information