Health and service provider registration form - v3

You do not need to complete this form if:

You are a disability service provider – please visit our disability services registration page.
You are interested in undertaking independent medical examinations for the TAC – please contact us at medical_examiners@tac.vic.gov.au
You have already registered as a TAC provider and need to update your bank details – please use our Update provider bank details form.

Service provider details

For this registration, are accounts payable to *

The health or service providerA business

Provider first name *

Provider last name *

Provider email *

Business name *

Trading as (if applicable)

Provider type

Choose your provider type from one of the lists below.

Once you make a selection, the other lists will be removed. Choose 'Clear selection' to see all the lists again.

AHPRA registered professionals *

Accredited professionals *

Other *

My provider type is not listed

Please note: Yoga or pilates studios do not meet the TAC's requirements as a gym/sports complex. Please see our webpage about where TAC clients can do a gym/swim program for more information.

If your provider type is not listed, your service may not be payable under the Transport Accident Act (1986).

Please visit our provider webpage at tac.vic.gov.au/providers for a list of providers the TAC can pay.

If a TAC client has approached you for your service, please refer them back to their TAC claims manager to discuss their support needs.

If you have already provided a service to a TAC client, please contact the TAC client's Claims Manager to discuss your options.

ABN of the individual or organisation payable *

AHPRA number *

School only

I confirm that the school listed on this form is registered with Victorian Registration & Qualifications Authority (or relevant other State body) *

Psychologist only

Are you a *

Fully qualified psychologistProvisional psychologist

Under the Transport Accident Act, 1986, the TAC can only register a provisional psychologist who has graduated. If you are still a student, you will not be able to register at this time.

As a provisional psychologist, I declare that I:

1. have completed my Australian Psychology Accreditation Council fifth year of study
2. have completed my degree, and
3. am completing my internship year under the supervision of an AHPRA board approved supervisor.

*

Please upload proof of degree conferral *

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Orthoptist

Please select and provide one of the following to support your registration *

Medicare numberCopy of Degree certificateeQuals linkCopy of current Australian Orthoptic Board registration

Speech therapist/pathologist

Please select and provide one of the following to support your registration *

Medicare numberCopy of Degree certificateeQuals linkCopy of current Speech Pathology Australia membership

Social worker

Please select and provide one of the following to support your registration *

Medicare numberCopy of Degree certificateeQuals linkCopy of current Australian Association of Social Workers membership

Physical educator/exercise physiologist

Please select and provide one of the following to support your registration *

Medicare numberCopy of Degree certificateeQuals linkCopy of current Exercise and Sports Science Australia Accreditation

Prosthetist/orthotist

Please select and provide one of the following to support your registration *

Medicare numberCopy of Degree certificateeQuals linkCopy of current Australian Orthotic Prosthetic Association membership

If orthoptist/speech therapist/social worker/Phys ed or prosthetist proof choice is medicare

Medicare number *

If orthoptist/speech therapist/social worker/Phys ed or prosthetist proof choice is degree

Please upload a copy of your Degree certificate *

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If orthoptist/speech therapist/social worker/Phys ed or prosthetist proof choice is eQuals

Please paste the link to your eQuals below *

Please upload a copy of your current Australian Orthoptic Board registration *

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Please upload a copy of your current Australian Orthotic Prosthetic Association membership *

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Please upload a copy of your current Exercise and Sports Science Australia Accreditation *

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Please upload a copy of your current Australian Association of Social Workers membership *

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Please upload a copy of your current Speech Pathology Australia membership *

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Allied health assistants only

Name of the recommending physiotherapist, occupational therapist or speech pathologist you work for *

What is your AHA grade? *

Is this an actual or equivalent grade? *

ActualEquivalent

Information about AHA grades is available in the Allied health policy on our website.

TAC claim number *You must have a TAC client you intend to work with to register as an Allied Health Assistant with the TAC.

Please upload a copy of your current membership with Audiology Australia *

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Please upload a copy of your current Driver Instructor Authority from VicRoads (or equivalent state body) *

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Please upload a copy of your current accreditation from the National Accreditation Authority for Translators and Interpreters *

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Please upload a copy of your current membership with the Dietitian Association of Australia *

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Hospital provider number *

Is this a public or private hospital?

PublicPrivate

TAC claim number for your approved services *

Service location *

Street address *Street address line 2

City *

State *

Postcode *

Country

Medicare service provider number for this address (if applicable)

Add another service location?

YesNo

Service location address

Medicare number for this location (if applicable)

Contact details for remittances

Who should the TAC send remittances to? *

A personA businessA billing agent

Person details

First name *

Last name *

Phone number *

Email *

Postal address *

Street address *Street address line 2

City *

State *

Postcode *

Country

Business details

Business name *

Business contact person's full name *

Phone number *

Email *

Postal address *

Street address *Street address line 2

City *

State *

Postcode *

Country

Billing agent details

Billing agent name *

Phone number *

Email *

Postal address *

Street address *Street address line 2

City *

State *

Postcode *

Country

Bank account details

Is this a personal or business bank account? *

PersonalBusiness

Name of bank or financial institution *

BSB number (no spaces or dashes) *

Account number (no spaces) *

Name/s of account holders *

Name of account *

Your privacy

The TAC will use this information in accordance with the Privacy and Data Protection Act 2014. We will use this information to register you as a TAC provider for the first time.

We will use your bank account details to make EFT payments to you.

We may use this information to contact you, provide general TAC news and information and for reasonable secondary purposes.

For more information, please see our Privacy policy.

This calc is used to generate a number to show the 'other' declaration for driving instructors and interpreters, listed in the 'Accredited professionals' drop-down.

I have read, understood and agree to the TAC's provider acknowledgement. *

By completing this registration, you declare that the information provided in this application is true and correct at the time of the application and agree to be bound by the terms and conditions in this application.

You acknowledge and agree:

To deliver the service in accordance with TAC approvals, policies, provider guidelines and the clinical framework. The registered provider is responsible and liable for any subcontracting arrangements.
To maintain accurate and complete records of the services performed.
To provide the TAC, if requested, with documentation, evidence or further information in regard to the services you provide.
That the TAC can disclose relevant information to external authorities in accordance with the Transport Accident Act 1986 and the TAC privacy policy.
To comply with any regulatory obligations or requirements under law.
Prioritise the safety and wellbeing of children and young people during service delivery and comply with any laws relating to the protection of children including the Child Safe Standards.
To handle personal information (including health and sensitive information) in accordance with the Privacy and Data Protection Act 2014 (Vic) and Health Records Act 2001 (Vic), including the Information Privacy Principles and Health Privacy Principles, and any other State laws regarding the handling of personal information, in the same way, and to the same extent as the TAC are bound by these laws;
To reimburse the TAC for any expenses, damages and costs that the TAC has to pay because of any negligent, illegal or fraudulent actions or omissions, or misconduct or breach of these terms and conditions, by you or any of your sub-contractors when providing services. However, you don't have to pay for anything that happened because of the TAC's negligent, illegal or fraudulent actions or omissions, or misconduct or breach of these terms and conditions;
That the TAC has the right to review or revoke your registration should you fail to comply with the TAC’s registration or service delivery requirements or policies outlined in this application form, or if you are no longer delivering services to TAC clients;
Subject to the TAC's legal obligations, the TAC has the right to suspend payment for services delivered or seek recovery of payments made, in circumstances where you fail to comply with the TAC registration or service delivery requirements or policies outlined in this application form.

I have read, understood and agree to the TAC's provider acknowledgement. *

By completing this registration, you declare that the information provided in this application is true and correct at the time of the application and agree to be bound by the terms and conditions in this application.

You acknowledge and agree:

To deliver the service in accordance with TAC approvals, policies and the provider guidelines.
The registered provider is responsible and liable for any subcontracting arrangements.
To maintain accurate and complete records of the services performed.
To provide the TAC, if requested, with documentation, evidence or further information in regard to the services you provide.
That the TAC can disclose relevant information to external authorities in accordance with the Transport Accident Act 1986 and the TAC privacy policy.
To comply with any regulatory obligations or requirements under law.
To prioritise the safety and well-being of children and young people during service delivery and comply with any laws relating to the protection of children, including the Child Safe Standards.
To handle personal information (including health and sensitive information) in accordance with the Privacy and Data Protection Act 2014 (Vic) and Health Records Act 2001 (Vic), including the Information Privacy Principles and Health Privacy Principles, and any other State laws regarding handling of personal information, in the same way and to the same extent as the TAC are bound by these laws.
To reimburse the TAC for any expenses, damages and costs that the TAC has to pay because of any negligent, illegal or fraudulent actions or omissions, or misconduct or breach of these terms and conditions, by you or any of your sub-contractors when providing services. However, you don't have to pay for anything that happened because of the TAC's negligent, illegal or fraudulent actions or omissions, or misconduct or breach of these terms and conditions.
That the TAC has the right to review or revoke your registration should you fail to comply with the TAC’s registration or service delivery requirements or policies outlined in this application form, or if you are no longer delivering services to TAC clients.
Subject to the TAC's legal obligations, the TAC has the right to suspend payment for services delivered or seek recovery of payments made, in circumstances where you fail to comply with the TAC registration or service delivery requirements or policies outlined in this application form.

Please declare any current or anticipated events, matters or circumstances that may impact the operations of your organisation or the delivery of services applied for (including financial and legal)

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