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Country Care Group - Health provider registration
Use this page to register for access to this contract.
* Country Care Group collects your personal information for the purposes of creating an equipment portal account for you. We will only disclose this information when required to by law. You can get a copy of the information we hold about you by contacting us on 1800 822 224
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Organisation Address:
Organisation Phone Number:
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Provider Number:
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Provider Details
First Name
Surname
ProviderType
Organisation Details
*** Please note that CCG Contracts allows for multiple organisations per account. If you work at more than one organisation, please list the subsequent organisations in the Additional Comments.
Organisation Name
Address
Locality
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State
Postcode
Phone Number
Mobile Number
Fax Number
Authority to prescribe
Yes, I am authorised and would like to prescribe for DVA clients (Department of Veteran Affairs)
Yes, I am authorised and would like to prescribe for TAC clients (Transport Accident Commission)
Yes, I am authorised and would like to prescribe for MSH DES clients (Metro South Health Domiciliary Equipment Services)
Yes, I am authorised and would like to prescribe for MAIB clients (Motor Accident Insurance Board)
DVA
TAC
MAIB
Provider Number
Preferred Supplier
Preferred Builder
Preferred Supplier
Preferred Builder
Preferred Supplier
Preferred Builder
Preferences
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Additional Comments
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