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.
This information was printed Tuesday 21 May 2019 from https://www.humanservices.gov.au/organisations/health-professionals/forms/hw012 It may not include all of the relevant information on this topic. Please consider any relevant site notices at https://www.humanservices.gov.au/individuals/site-notices when using this material.

Page last updated: 13 November 2018