New Affiliated Provider agreement

Please complete the form below and one of our Partnership Managers will be in touch.

The information we, Southern Cross Medical Care Society (Southern Cross), collect here will be used to draft an Affiliated Provider agreement with the intention to contract for services. Upon agreement to the terms and conditions of an Affiliated Provider agreement, the eligible practitioner(s), email(s), specialty, location(s) of practice and appointment phone number(s) noted here will be published on Healthcare Finder, our database of practices and providers that is publicly available . We may also use the information provided here to administer payments to you, send you information about our products and services, newsletters, surveys and to communicate with you about relevant matters.

You and your listed providers are entitled to access and request correction of the personal information that we hold about you and your listed providers.

To complete this form make sure you have:

your practice(s) and listed provider(s) details
your practice bank account details (ie: deposit slip or bank deposit screen shot)
enough time to complete the form.

Approximate time to complete this form is between 10 - 15 minutes.

The name of the person that has sent you this form to complete *

Agreement type

Please select one of the following *

Company agreement

Individual agreement

Registered company name *

Full legal name *

Agreement contact details

The person who will be authorised to request changes and receive notices under the Affiliated Provider agreement.

Title *

Please select Please select Dr Mr Mrs Ms Miss Mx Prof Assoc Prof

First name *

Last name *

Preferred name (if different)

Postal address *

Suburb

Town/city *

Postcode *

Email *

Phone

Mobile *

Preferred contact method *

Please select Please select Email Phone

Affiliated Provider agreement and variation signing options

All Southern Cross Affiliated Provider agreements are available to be signed digitally via Secured Signing.

Which method of digital signing would you prefer? *

Digital signing with reviewer

Standard digital signing

Authorised signatory

I will be the authorised signatory using the Agreement contact details listed above

I will provide details for the authorised signatory

Signatory details

Title *

Please select Please select Dr Mr Mrs Ms Miss Mx Prof Assoc Prof

First name *

Last name *

Preferred name

Postal address *

Suburb

Town/city *

Postcode *

Email *

Phone

Mobile *

Preferred contact method *

Please select Please select Email Phone

Reviewer details

I will be the reviewer using the Agreement contact details listed above

I will provide details for the reviewer

Please provide reviewer details

First name *

Last name *

Email *

Mobile *

Practice details

Note: If you have more than one practice, you can submit the details after completing this form.

Building name

Practice location

Street address *

Suburb

Town/city *

Postcode *

Email

Phone *

Website

Practitioner (listed provider) contact details

Note: If you have more than one listed provider, you can submit their details after completing this form.

Title *

Please select Please select Dr Mr Mrs Miss Ms Prof Assoc Prof

First name *

Last name *

Preferred name (if different)

Postal address *

Suburb

Town/city *

Postcode *

Email *

Phone *

Preferred contact method *

Please select Please select Email Phone Mobile

Professional body

Vocational scope

Professional body

Vocational scope

Sub-specialty

Special interests

Add another specialty

Professional body

Vocational scope

Professional body

Vocational scope

Sub-specialty

Special interests

Add another specialty

Professional body

Vocational scope

Professional body

Vocational scope

Sub-specialty

Special interests

Registration number *

Is provider new to practicing in private?

Please select Please select Yes No

Provider Web users

Provider Web is our web-based portal you will use to submit approval applications and request payment from us for your contracted services. To select the appropriate access for the Provider Web users, please view page 13 of the Provider Web Basics Guide ‘Giving the right access’. Learn more about Provider Web.

Please provide all user details below.

First name *

Last name *

Email *

Phone *

Access type *

Please select Please select Admin User

Add another user

First name *

Last name *

Email *

Phone *

Access type *

Please select Please select Admin User

Add another user

First name *

Last name *

Email *

Phone *

Access type *

Please select Please select Admin User

Add another user

First name *

Last name *

Email *

Phone *

Access type *

Please select Please select Admin User

Bank account details

Please attach either a deposit slip or screenshot showing:

Bank logo
Bank account name
Bank account number

Accepted file types: DOC, DOCX, PDF, JPEG, JPG or PNG (Max file size 2MB).

Attach bank account details *

GST number *

Email address for remittances *

Add more email addresses (up to five)

Remittance format *

Please select Please select PDF CSV

Services and volumes

What services will you be providing on this agreement? *

On average, how many Southern Cross members do you see each week? *

Please select Please select Less than 3 Between 4 - 10 Between 11 - 20 Between 21 - 30 More than 31

Supplementary information

Please advise of any serious/adverse matters you are aware of and believe you should draw our attention to.

Declaration

By completing and submitting this form, you agree that:

to the best of your knowledge you have properly considered the matters and the information provided above is accurate and complete,
you have communicated any serious/adverse matters to Southern Cross,
you have the necessary permissions for us to collect, store and use any personal information provided in this information form for the purposes of considering your request,
nothing in this form creates any obligation of any kind on Southern Cross (including but not limited to any process contract between us) and Southern Cross at its entire discretion may decline to progress or accept this request,
Southern Cross may require further information before proceeding and / or making any decision.

I declare that details above are accurate and agree to the terms *

New Affiliated Provider agreement

To complete this form make sure you have:

Agreement type

Agreement contact details

Affiliated Provider agreement and variation signing options

Signatory details

Please provide reviewer details

Practice details

Practitioner (listed provider) contact details

Provider Web users

Bank account details

Services and volumes

Supplementary information

Declaration

What we offer

Who we are for

Other Southern Cross Group sites

Important information

Quick links

Help links

Got to a Southern Cross Website