THELMA New Provider Application Form
Applicant Details
(
Denotes Required Field )
Applicant First Name
Applicant Surname
Your Position Title
Organisation Name
Organisation Type
Select
Hospital
Day Surgery
Medical Practice
Other
Subtype
Select
Private
Public
Organisation Address
Suburb/Town
Postcode
State
Select
NSW
VIC
SA
WA
NT
QLD
TAS
ACT
Your Direct Line
(
)
Applicant Email
Name of hospital or day surgery group that you belong to?
What patient administration system or PMS do you use for billing?
How many beds does your hospital have?
Please Select Required Transactions:
Fund Membership Eligibility Check
Radiology Claim
Inpatient Hospital Claims to Funds
Pathology Claim
Inpatient Medical Claims to Funds
Informed Financial Consent
Medical Claims to Medicare
Alternatively you can contact a THELMA Provider Sales Representative on (02) 9902 7700