Healthcare Identifiers Service

 1. Health Professional's details

1. HPI-I number:
2. Full name: *
3. Date of birth: *
4. Gender: * Male
   Female
5. Address: (as held by AHPRA)
6. Street Address:
7. State: ACT NSW QLD VIC TAS SA WA NT
8. Post Code:

 2. Healthcare Provider Directory Entry

CONSENT: I consent to publish my details, as listed below, in the Healthcare Provider Directory. Please note if consent is provided, the minimum default fields for listing in the directory include Health Professional’s name and Preferred Address.

1. * Please supply a business address to be published in the HPD:
   
   
   
2. Street Address:
3. State: ACT NSW QLD VIC TAS SA WA NT
4. Post Code:
5. Details I would like to be published in the Healthcare Provider Directory for the purposes of the Healthcare Identifiers Service (tick appropriate boxes):
6. Health Professional’s name
7. Business Address
8. Gender
9. Health Professional’s registration details
10. Daytime phone number
11. Mobile phone number
12. Fax number
13. Pager number
14. Email address
15. Privacy Note: The information on this form, with your consent, will be used to list your details in the Healthcare Provider Directory.

 3. Healthcare Provider’s Public Key Infrastructure (PKI)

1. I would like Healthcare Identifiers access permissions added to my existing PKI individual certificate
2. Registration Authority (RA) number:
3. I do not currently have a PKI certificate for other Medicare purposes, and would like to request a PKI certificate for the purposes of accessing the HI Service.
4. Please supply a business address for the new PKI certificate to be mailed to (if different to above):
   
   
   
   • Street Address:
   • State: ACT NSW QLD VIC TAS SA WA NT
   • Post Code:
     
     
5. Privacy Note: If a PKI certificate is requested, this information will be used to register and store your details for the issuance of a Public Key Infrastructure (PKI) certificate and to list your details in the PKI Healthcare Public Directory. This information will be disclosed to a certificate issuance authority for issuing PKI keys and certificates, or as authorised or required by law.

 4. Contact Details

1. Contact Person: *
2. Best day and time to contact: *
3. Phone: *