Application for an initial Medicare provider
number for a dentist, dental specialist or
dental prosthetist
Purpose of this form
For more information
Complete this form if you are a dentist, dental specialist or dental
prosthetist and would like to apply for an initial Medicare provider
number.
Go to humanservices.gov.au/healthprofessionals or call 132 150
Monday to Friday, between 8.30 am and 5.00 pm, Australian Eastern
Standard Time.
If you have an existing provider number issued by the Australian
Government Department of Human Services, you must apply for an
additional location Medicare provider number. By accessing Health
Professionals Online Services (HPOS), you can immediately create an
additional location Medicare provider number. If you do not currently
have access, you can register for a Provider Digital Access (PRODA)
account at humanservices.gov.au/proda
Note: Call charges may apply.
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Access to Medicare benefits
Dentists, dental specialists or dental prosthetists must apply for a
unique provider number for each location. In addition, a dentist,
dental specialist or dental prosthetist who is also a medical
practitioner must apply for a unique provider number in each health
discipline.
Medicare provider numbers are allocated to enable participation in
the Medicare program and to provide a method of uniquely
identifying the provider and the location from which a service is
provided. The provider number also allows a dentist or dental
specialist to request certain diagnostic imaging services as set out in
the Medicare Benefits Schedule (MBS).
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If applying for an additional provider number where a home address
or school will be used as your practice location, you will need to
complete an Application for an Additional location Medicare
provider number form (HW020) manually and send it to the
Department of Human Services for approval.
Your application and supporting documentation should be sent to the
Department of Human Services before your proposed
commencement date.
The Health Insurance Regulations provide that, for Medicare
purposes, a valid account or receipt must contain the provider’s
name and either:
• the address of the place of practice from which the service was
provided, or
• the provider number for the place of practice from which the
service was provided.
You should not commence billing until the Department of Human
Services has advised you of your provider number and Medicare
eligibility.
The information provided in this application and obtained from other
organisations, may be used by the Department of Veterans’ Affairs to
determine your eligibility to receive benefits for health services
rendered under the Veterans’ Entitlement Act 1986.
Payment of claims could be delayed or disallowed where it is not
possible from account details to clearly identify the services that
qualify for Medicare benefits, or identify the provider as a registered
person at the place of practice.
Filling in this form
• Please use black or blue pen
• Print in BLOCK LETTERS
• Mark boxes like this
with a ✓ or 7
Eligibility
Dentist
A dentist must have current registration with the Dental Board of
Australia.
Returning your form
Check that all required questions are answered and that the form is
signed and dated.
Your application will be returned to you if all relevant
documentation is not supplied or is incomplete.
Send the completed form(s) to:
Dental Specialist
A dental specialist must hold specialist registration with the Dental
Board of Australia.
Dental Prosthetist
Department of Human Services
Provider Eligibility Section
GPO Box 9822
in your capital city
A dental prosthetist must be registered or licensed with the relevant
state or territory registration/licensing board to engage in the
practise of dental prosthetics.
While conditions or limits are imposed under relevant state or
territory law prohibiting a dental prosthetist from providing dental
prosthetic services to patients, the dental prosthetist is not eligible to
register with the Department of Human Services to provide dental
health services.
or
Fax:
NSW/ACT 02 9895 3439 VIC/NT 03 9605 7984 QLD 07 3004 5634
HW017.1610 (formerly 3301)
SA/TAS 08 8274 9307
WA 08 9214 8201
Students who are registered or licensed under relevant state or
territory law in order to complete a course of study or supervised
training in dental prosthetics, are not eligible to register with the
Department of Human Services to provide dental health services.
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* ‘Short-term’, ‘interim’ or ‘provisional’ registration
Personal contact details
Dental prosthetists whose registration or licence to practise is
granted for a ‘short-term’, ‘interim’ or ‘provisional’ period only, will
be registered by the Department of Human Services for the stated
period only. After this time, registration will only be continued where
the dental prosthetist provided the Department of Human Services
with evidence of their current registration or licence to practise as a
dental prosthetist.
If you tick the general correspondence box in question 4, your postal
or email address will be recorded and may be used for mailing
purposes.
Please keep your details up-to-date to make sure important
information reaches you.
You can update your contact details through HPOS at
humanservices.gov.au/hpos
* ‘Company’ registration
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Dental prosthetists whose registration or licence to practise is
granted in the name of a ‘Company’ are not eligible to register with
the Department of Human Services. To register with the Department
of Human Services the dental prosthetist must provide the
Department of Human Services with evidence that they, as an
individual, are registered or licensed to practise as a dental
prosthetist under relevant state or territory law.
Claiming
Electronic Funds Transfer (EFT) payments
Your Medicare and Department of Veterans’ Affairs (DVA) benefits for
bulk bill claims can be paid into a nominated bank account by
completing the EFT details at question 13 on this form.
Online claiming
If you are claiming online, you will need to complete a Banking
Details Online Claiming form (HW052) available at
humanservices.gov.au/hpforms
* ‘Non practising’ registration
Dental prosthetists whose registration or licence to practise is
granted as ‘non practising’ are not eligible to register with the
Department of Human Services.
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* ‘Limited’, ‘specific’ or ‘special purpose’ registration
Some dental prosthetists are prohibited from providing dental
prosthetic services to patients where their registration or licence to
practise is granted as ‘limited’, ‘specific’ or for a ‘special purpose’.
Where a dental prosthetist is allowed by law to provide dental
prosthetic services to patients under a ‘limited’, ‘specific’ or ‘special
purpose’ registration or licence, the person will need to provide the
Department of Human Services with evidence that this is the case to
be registered by the Department of Human Services. This may be in
the form of advice from the relevant state or territory registration
board.
Cleft Lip and Cleft Palate Scheme
Dentists
Dentists registered with the Dental Board of Australia are entitled to
perform simple extraction services and the general and
prosthodontic services listed in the MBS.
Orthodontists
Dental specialists registered with the Dental Board of Australia will
be able to access relevant items under the MBS.
Dental prescriber number
A registered dentist or dental specialist who intends to prescribe
medication under the Pharmaceutical Benefits Scheme must
complete an Application for approval to prescribe medications
under the Pharmaceutical Benefits Scheme by a registered
dental practitioner form (PB151) available from
humanservices.gov.au/hpforms
A dental prosthetist is not eligible to prescribe medication under the
PBS.
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HW017.1610 (formerly 3301)
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Application for an initial Medicare provider
number for a dentist, dental specialist or
dental prosthetist
Personal details
1 Dr
Mr
Family name
Qualifications
Mrs
Miss
Ms
7 Please select the dental category for which a provider number
Other
is required:
Dentist
Dento-maxillofacial Radiology
First given name
Endodontics
Oral medicine and/or Oral Pathology
Second given name
Oral and Maxillofacial Surgery
2 Your date of birth
/
Oral Surgery
/
Dental Prosthetist
3 Your gender
Orthodontics
Male
Female
Paedodontics
Periodontics
Personal contact details
Prosthodontics
4 Postal and/or email address to be used for:
Special Needs Dentistry
8 Professional qualification
This application only
General correspondence
5 Postal address
Place obtained
Year obtained
Postcode
6 Daytime phone number
(
)
Registration
Mobile phone number
I have attached a copy of my registration certificate or
written confirmation from the Dental Board of Australia
advising current specialist registration status.
Fax number
(
)
9 Registration number
Pager number
Specialty
Email
@
HW017.1610 (formerly 3301)
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Required location
Bank account details
10 Provide details of the required location(s) for the provider
All payments are made through Electronic Funds Transfer (EFT).
Payments cannot be made via EFT if the nominated account has
restrictions on EFT deposits.
number
The practice address is the address from which you render
services. If you provide services at more than one practice
address attach a separate sheet with details for each of those
practice locations. Do not provide PO Box addresses.
14 Name of bank, building society or credit union
Branch where the account is held
Full practice address
Practice name
Branch number (BSB)
Building name
Account number (this may not be the card number)
Unit
Suite
Street number
Shop
Floor number
Account held in the name(s) of
Street name
Privacy notice
Suburb
15 Your personal information is protected by law (including the
State
11 Start date
/
Privacy Act 1988 ) and is collected by the Australian Government
Department of Human Services for administering of payments
and services. This information is required to assist with your
application or claim.
Your information may be used by the Department, or given to
other parties: where you have agreed to that; or where it is
required or authorised by law (including for the purpose of
research or conducting investigations).
You can get more information about the way in which the
Department will manage your personal information, including
our privacy policy, at humanservices.gov.au/privacy
Postcode
End date
/
/
/
12 Daytime phone number
(
)
Fax number
(
)
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Email
Declaration
16 I declare that:
@
• the information I have provided in this form is complete and
correct.
I understand that:
• giving false or misleading information is a serious offence.
13 Does your registration allow you to work at the location(s)
listed?
No
A provider number cannot be allocated for the
required location(s).
Yes
Applicant’s full name
Applicant’s signature
Date
/
HW017.1610 (formerly 3301)
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/
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