Provider Directory Data authorised recipient data release application or renewal form (MO003)

Use this form to seek authorisation for a contact person to access to data and receive correspondence in the Provider Directory System.

This form must be signed by the Chief Executive Officer or the Public Officer of an incorporated body, for example, Health Sector Entity Representative.

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

Page last updated: 19 September 2018