HI Service - My Health Record system - application to register a contracted service provider organisation record form (HW012)

Use this form to register a Contracted Service Provider with the Healthcare Identifiers Service or the My Health Record system.

You can also request a National Authentication Service for Health (NASH) Public Key Infrastructure (PKI) Certificate for your organisation.

You must read and agree to the terms and conditions of use when applying for a NASH PKI certificate. These are on pages 10 and 11 of this form.

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This PDF is fillable. Download this form and complete it on your device, or print it and complete it by hand.

Page last updated: 13 November 2018