Complete this form to notify the Australian Government Department of Human Services (Human Services) of additional general practitioners or nurse practitioners who join the practice after the practice has registered for the Practice Incentives Program (PIP) and/ or the Practice Nurse Incentive Program (PNIP). This applies for all
PIP and PNIP practices. Individual general practitioners who meet the eligibility criteria for the PIP Procedural General Practitioner Payment and choose this practice to receive those payments, are to complete the Procedural General Practitioner details section of this form.
For more information about incentive programs for practices, go to our website www.
humanservices.gov.au/healthprofessionals >
Incentives and Allowances or email pip@humanservices.gov.au or pnip@humanservices.gov.au
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.
Health Professionals Online Services (HPOS) provides secure and convenient online services for health professionals and administrators.
Using your Medicare Public Key Infrastructure (PKI) Individual certificate, you can update your practice details through HPOS.
Changes you make through HPOS are effective immediately. To register for a Medicare PKI certificate and to find out more about
HPOS, go to www.
humanservices.gov.au/hpos
While you are waiting for your Medicare PKI certificate to be issued, you may complete this form and send it to us for manual processing.
Please note that delays may occur.
A separate form for each additional general practitioner or nurse practitioner is required.
• general practitioners
• non-specialist medical practitioners, known as other medical practitioners, who provide non-referred services and are not general practitioners
• fellows of the Royal Australian College of General Practitioners
(RACGP)
• fellows of the Australian College of Rural and Remote Medicine
(ACRRM)
• vocationally registered general practitioners, and
• medical practitioners undertaking approved training.
• endorsed as a nurse practitioner by the Nursing and Midwifery
Board of Australia.
Registration requirements for nurse practitioners can be found at the www.
Nursing and Midwifery Board of Australia website nursingmidwiferyboard.gov.au
Participating nurse practitioners who provide Medicare services are not eligible to claim those hours under the PNIP.
IP003.1406 (formerly 2746)
• 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.
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 Programs
GPO Box 2572
ADELAIDE SA 5001 or
Fax: 1300 587 696
The practice participates in the:
Tick ALL that apply
Practice Incentives Program
Practice Nurse Incentive Program
Practice ID
Australian Business Number (ABN)

The practice address is the address from which you render services.
Full address – main practice location
Practice name
Building name
Unit
Street number
Suite
Street name
Shop Floor number
Suburb
State Postcode
Practice phone number
( )
Fax number
( )
Email
@
Applicants are to complete all questions in the general practitioner or nurse practitioner details section of this form. Procedural
General Practitioners must complete questions 13 and 14.
Full name of general practitioner or nurse practitioner
Do you consent to the use of your Human Services and
Department of Veterans’ Affairs service data when calculating the practice’s incentive payment(s)?
No If you do not consent, Human Services will exclude your data when calculating the practice’s payment(s).
This will affect the level of payment to the practice.
Yes
Are you a current provider at the practice?
No This will affect the level of payment to the practice for the PNIP.
Yes
It is an entry requirement of both the PIP and the PNIP that all current practice general practitioners and nurse practitioners have current professional indemnity cover.
Do you have current professional indemnity cover?
No The practice is not eligible for the PIP and/or the PNIP.
Yes Give details below
Professional indemnity insurance company name
Expiry date
/ /
Policy number
Provider number for the main practice location
Start date at the practice
/ /
End date at the practice (if applicable)
/ /
If you have an Individual Medicare PKI certificate, you should provide the Registration Authority (RA) number below:
The RA number is located on the tag attached to the Medicare
PKI Universal Serial Bus (USB) Key or on the card sent with the
USB card reader.
The RA number will be used to allow access to the PIP and the
PNIP Online.
Provider number and address for each additional practice branch (if applicable).
Additional practice branch 1
Provider number
Full practice address
Building name
Unit
Street number
Suite Shop Floor number
Street name
Suburb
State
Postcode
Start date at the practice
/ /
End date at the practice (if applicable)
/ /
IP003.1406 (formerly 2746)

Additional practice branch 2
Provider number
Full practice address
Building name
Unit
Street number
Suite Shop
Street name
Floor number
Suburb
State
Postcode
Start date at the practice
/ /
End date at the practice (if applicable)
/ /
If you have more than 2 additional practice branches, attach a separate sheet with details.
Are you a Procedural General Practitioner (GP)?
A Procedural GP provides non-referred services, normally in a hospital theatre, maternity care setting or appropriately equipped facility, which in urban areas are typically the province of a specific referral-based specialty. These services are provided in obstetrics, surgery and anaesthetics. The PIP
Procedural GP Payment can only be made to 1 practice per 6 month reference period per Procedural GP. If you choose this practice to receive the Procedural GP Payment, indicate the provider number to be used below that is associated with this practice.
No Go to 15
Yes
Provider number
To be eligible for the PIP Procedural GP Payment, the practice must be located in Rural, Remote and Metropolitan Areas
(RRMA) 3–7 and meet the requirements as set out in the
Practice Incentives Program Procedural General www.
Practitioner Payment Guidelines , available from humanservices.gov.au/healthprofessionals > Incentives and Allowances > Practice Incentives Program
Tick ONE box that best applies to you:
Tier 1 I provide at least 1 procedural service in the
6 month reference period. Refer to the
Practice Incentives Program Procedural
General Practitioner Payment Guidelines for the definition of a procedural service.
Tier 2 I meet the Tier 1 requirements and provide procedural services after hours (as defined in the Practice Incentives Program Procedural
General Practitioner Payment Guidelines ) on a regular or rostered basis throughout the 6 month reference period.
Tier 3 I meet the Tier 2 requirements and provide 25 or more eligible surgical and/or anaesthetic and/or obstetric services in the 6 month reference period.
Tier 4 I meet the Tier 2 requirements and deliver
10 or more babies in the 6 month reference period.
Contact us on 1800 222 032 if you are a single general practitioner practice and may not meet the requirements of
Tier 4, but expect to meet the obstetric needs of your community.
General practitioners are individually assessed. Practices with more than 1 Procedural GP cannot count the combined number of deliveries to qualify for Tier 4. For more information on reference periods and the point-in-time date for the 6 monthly payments, refer to the Practice Incentives Program Procedural General
Practitioner Payment Guidelines .
Human Services must be advised in writing by no later than
7 days prior to the relevant point-in-time date if the required number of procedural services have not been provided in the
6 month reference period.
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 Program (PIP) and/or the Practice Nurse Incentive Program (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 that is 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 www.
humanservices.gov.au/privacy or by requesting a copy from the Department of Human Services.
IP003.1406 (formerly 2746)

I consent to :
• the Australian Government Department of Human Services accessing information, including personal information, held by itself or the Department of Veterans’ Affairs about medical services provided by me for the purposes of calculating payments for the practice.
I understand that :
• giving false or misleading information is a serious offence.
• the Australian Government Department of Human Services can make relevant enquiries and may access information for the purpose of calculating payments.
• the Australian Government Department of Human Services may provide reports regarding information and services provided by me to the authorised contact person(s).
• I must advise the Australian Government Department of
Human Services in writing of any changes to my arrangements by no later than 7 days prior to the relevant point-in-time date.
• if this is not done, incentive payments may be reduced or recovered and the practice’s eligibility for incentive programs may be affected.
I declare that :
• the information I have provided in this form is complete and correct.
• I have not claimed these procedural services at another practice (if applicable).
General practitioner’s full name
General practitioner’s signature
-
Date
/ / or
Nurse practitioner’s full name
Nurse practitioner’s signature
-
Date
/ /
Reset form
IP003.1406 (formerly 2746)
Office use only
PIP processing completed
Operator ID
Print form
Date processed Date forwarded to PNIP
/ / / /
PNIP processing completed
Operator ID
Date processed
/ /