A2 Medical Billing Service Registration

Full Name *

Address *

Suburb *

Postcode *

Phone number *

Fax number

Email address *

* required fields

Company Name *

Australian Business Number (ABN)

APHRA Registration Number

Qualifications

Specialities

Provider Number

Location

Preferred Payment Method Electronic Funds Tansfer Cheque

Name of the Bank Branch Name of Account BSB Number Account Number

No additional information required

How did you hear about us? (Optional)