Transfer Provider Number Information

Name*

First NameLast Name
Date of Birth*

DayMonthYear
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Current Association*

Australian Natural Therapies Association (ANTA)Australian Traditional Medicine Society (ATMS)Massage & Myotherapy Australia (MAMA)Massage Association of Australia (MAA)Myotherapy Association Australia (MA)Other
Current Association Member Number*
Name of Registered Training Organisation Qualification Completed at*
Qualification*
Year Completed Qualification*
Qualification Evidence*

Please upload a copy of your qualification
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If you have received a letter from your Registered Training Organisation (college) for health fund recognition such as AHM/Medibank, ARHG and HCF please upload it below.
Health Fund Letter of Compliance from RTO

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Please select the number of practices you work from?*

Provider Numbers 1*

Practice address and Provider number details