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.

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: 19 September 2018

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