Service Application Form ~ New Zealand

Subscribers Details

Please complete the application form below. (Required fields marked with *)

Practice/Organisation Name *
Practice/Org. Street Address *
Your software pack will be
sent to this address
Suburb *
City *
Country *
Post Code *
Postal Address
Only complete postal address if
different to street address
Suburb
City
Country
Post Code
Practice/Org. Telephone *    e.g. +64 9 1234567
Practice/Org. Fax *
Practice/Org. Email *
IPA / PHO
No. of Full Time Providers*
No. of Part Time Providers
   Total Part-Time Hours 
Contact Names
Practice/Org. Primary Contact*

Healthcare Providers
Please enter the names and provider numbers of the Healthcare Providers at your practice

Name e.g. Dr John Smith
Provider Number

Practice/Organisation Type *
Please tell us what type of practice or service you provide.

Other

Clinical Software *
Which of the following Clinical Software Systems does your practice use?

Other   

Site Support *
Please select which operating system you will be using.

Other   

Services

Service(s) Applied For: (please tick)

Full EDI Messaging (LABs, Claiming & Referrals)  Learn More
Electronic Claiming (GMS and ACC claims)  Learn More
SecurIT (Secure Internet Management Service)  Learn More
SecurIT for HealthPAC Pharmacy Claiming  Learn More
Pharmacy Claiming (Send claims via HealthLink)  Learn More

Comments or Special Delivery Instructions

Service Agreement *

Full Name
Position

I hereby apply on behalf of the afore mentioned practice / organisation to use the services
offered by HealthLink Ltd and agree to comply with all terms and conditions set out in the
Healthlink Service Agreement including all schedules published at healthlink.net.

  Can't view the Service Agreement? Click here to download the Adobe Reader