New listed provider

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.

Affiliated Provider agreement details

Please select Please select Yes No I have just submitted a new agreement request
 

You will need to complete a new agreement form if you do not already hold an Affiliated Provider agreement..

Listed provider contact details


Please select Please select Dr Mr Mrs Miss Ms Prof Assoc Prof
Please select Please select Email Phone
Please select Please select Yes No

Services, locations and volumes


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

Your details

We'll use these details to send you a summary of what has been requested.


Supplementary information


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.