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.

If you have a disability or impairment and use assistive technology, there are other ways you can do your business with us. You can use self service or request someone to deal with us on your behalf. If you can’t access our forms, please contact us. We can help you access, complete and submit them.

Page last updated: 13 November 2018

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