Practice Incentives
Change of authorised contact person(s)
Purpose of this form
Returning your form
Complete this form to notify the Australian Government Department
of Human Services of a change of authorised contact person(s) for
correspondence and phone enquiries relating to your Practice
Incentives Programme (PIP) and/or the Practice Nurse Incentive
Programme (PNIP).
Check that you have answered all the questions you need to answer
and that you have signed and dated this form.
Send the completed form to:
Department of Human Services
Incentive Programmes
GPO Box 2572
ADELAIDE SA 5001
or
Fax: 1300 587 696
Important information
Health Professionals Online Services (HPOS) provides secure and
convenient online services for health professionals and
administrators.
Practice details
Using your Medicare Public Key Infrastructure (PKI) Individual
Certificate, you can make claims and update your practice details
through HPOS. Lodgement through HPOS is effective immediately
and you will receive a return acknowledgement message.
1 The practice participates in the:
Tick ALL that apply
Practice Incentives Programme ✔
Practice Nurse Incentive Programme
To register for a Medicare PKI Certificate and to find out more about
HPOS, go to humanservices.gov.au/hpos
If you are unable to apply using HPOS, you can complete this form
and send it to us for manual processing.
2 Practice ID
www.
If the authorised contact person(s) have an individual PKI Certificate,
they should provide the Registration Authority (RA) number in the
space provided.
3 Australian Business Number (ABN)
The RA number is located on the tag attached to the PKI Universal
Serial Bus (USB) Key, or on the card sent with the USB card reader.
4
The practice address is the address from which you render
services.
The RA number will be used to allow access to the PIP and/or PNIP
online.
Full address – main practice location
Practice name
For more information
Building name
For more information about incentive programmes for practices, go
to our website humanservices.gov.au/pip or email
pip@humanservices.gov.au or
pnip@humanservices.gov.au
www.
Unit
Street name
Suburb
Filling in this form
Please use black or blue pen
Print in BLOCK LETTERS
Mark boxes like this
with a ✓ or 7
•
Where you see a box like this
Go to 5 skip to the question
number shown. You do not need to answer the questions in
between.
State
Postcode
5 Practice phone number
(
)
Fax number
(
)
Email
@
IP018.1505 (formerly 1086)
Shop
Street number
If you need assistance completing this form, call the incentives
enquiry line on 1800 222 032 Monday to Friday, between 8.30 am
and 5.00 pm, Australian Central Standard Time.
Note: Call charges apply from mobile phones.
•
•
•
Suite
1 of 3
Floor number
Authorised contact person details
Additional authorised contact person
The authorised contact person(s) must be authorised by the
owner(s) of the practice to advise of changes and will be the
person(s) to whom all correspondence is addressed.
The authorised contact person(s) is responsible for notifying the
Department of Human Services in writing of any changes in
practice arrangements by no later than 7 days before the
relevant point-time-date.
Dr
Mr
Mrs
Miss
Ms
Authorised contact person’s full name
Other
Position held
Authorised contact person’s signature
6 Do you want to add an additional authorised contact person(s) to
the practice profile?
No
Go to 7
Yes
Give details below
Primary authorised contact person
Dr
Mr
Mrs
Miss
Ms
Authorised contact person’s full name
RA number (if applicable)
Start date
Other
/
/
7 Do you want to remove a current authorised contact person(s)
Position held
from the practice profile?
No
Go to 8
Yes
Give details below
Authorised contact person 1
Authorised contact person’s signature
Authorised contact person’s full name
RA number (if applicable)
End date
/
Start date
/
Authorised contact person 2
/
Authorised contact person’s full name
Secondary authorised contact person
Dr
Mr
Mrs
Miss
Ms
Authorised contact person’s full name
/
Other
End date
/
/
Authorised contact person 3
Position held
Authorised contact person’s full name
Authorised contact person’s signature
End date
-
/
RA number (if applicable)
Start date
/
/
IP018.1505 (formerly 1086)
2 of 3
/
Privacy notice
Individual/Partner/Associate/Authorised Representative 2
Full name
8 Your personal information is protected by law, including by the
Privacy Act 1988.
Personal information and other information about a practice that
is participating in the Practice Incentives Programme (PIP) and/
or the Practice Nurse Incentive Programme (PNIP), or is applying
to participate in the PIP and/or PNIP, is collected by the
Australian Government Department of Human Services for the
assessment and administration of PIP and/or PNIP payments
and services. This information will be disclosed to the
Department of Health and the Department of Veterans’ Affairs to
enable that department to administer aspects of PIP and/or PNIP,
for statistical and research purposes and to inform policy
development.
The Department of Human Services may use or disclose your
personal information for other purposes where required or
authorised by law, or if you agree.
You can get more information about the way in which the
Department of Human Services will manage your personal
information, including our privacy policy, at
humanservices.gov.au/privacy or by requesting a copy from
the Department of Human Services.
Signature
Date
/
/
Individual/Partner/Associate/Authorised Representative 3
Full name
Signature
Date
/
/
www.
Individual/Partner/Associate/Authorised Representative 4
Full name
Declaration
If there are multiple practice owners, the signatures of 2 practice
owners or authorised representatives are required.
Signature
-
9 I/We declare that:
•
the information I/we have provided in this form is complete
and correct.
I/We agree to:
• advise of any changes to practice details no later than
7 days before the relevant point-in-time date.
I/We understand that:
• if this is not done incentive payments may be reduced or
recovered and the practice’s eligibility for the Practice
Incentives Programme and/or the Practice Nurse Incentive
Programme may be affected.
• the Australian Government Department of Human Services
may conduct compliance audits and the practice may be
required to provide information as evidence of compliance
with the Practice Incentives Programme and/or the
Practice Nurse Incentive Programme eligibility
requirements and that failure to do so may result in past
payments being recovered and/or future payments being
suspended or ceased.
• giving false or misleading information is a serious offence.
Date
/
/
Individual/Partner/Associate/Authorised Representative 5
Full name
Signature
Date
/
/
Reset form
Office use only
PIP processing completed
Operator ID
Individual/Partner/Associate/Authorised Representative 1
Full name
Date processed
/
Signature
/
Date forwarded to PNIP
/
PNIP processing completed
Operator ID
Date
/
Date processed
/
IP018.1505 (formerly 1086)
/
3 of 3
/
/
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