THELMA New Provider Application Form  

Applicant Details

( Denotes Required Field )
Applicant First Name
Applicant Surname
Your Position Title

Organisation Name

Organisation Type Subtype
Organisation Address
Suburb/Town

  Postcode   State

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) 9199 8000