HICAPS Accounts Online Registration Form

HICAPS Accounts Online – Upgrade/Create Access Request
Step 1 Determine level of access required.
Step 2 Complete the form below and have it signed as indicated.
Please note: only the owner of your practice may apply to have access levels upgraded. If the owner of your practice is not
the same person as the owner of the Settlement Account, in addition to your practice owner signing Part D below, you will
also need to have the owner of the Settlement Account sign it where indicated.
When completed: Fax to us on 1300 725 726 or Mail to GPO Box 84A, Melbourne Vic 3001.
A
Your Practice Details
Company Name
Account ID
Terminal Number
Upgrade Provider Access
Access Level required*
(Please tick one box below)
Title
First Name
Surname
Provider Number
Level 3 Level 2 Level 1
Title
First Name
Surname
Provider Number
Level 3 Level 2 Level 1
Create Additional User Access
Title
First Name
Surname
Position ie. Practice Manager
Access Level required*
(Please tick one box below)
Level 3 Level 2 Level 1
Title
Surname
Position ie. Practice Manager
Level 3 Level 2 Level 1
First Name
For details on access levels please refer to summary table on the reverse side.
*
B
Your Email Address for HICAPS to send confirmation
C
Acknowledgement and Consent
By signing this Upgrade Access Level Request (“Request”), I/we:
1. agree to notify HICAPS Pty Ltd (“HICAPS”), of any proposed change (if applicable) in the:
(a) authorised signatories to the Settlement Account; and
(b) ownership of my/our practice;
2.represent and warrant to HICAPS that prior to submitting this Request, I/we obtained the approval and consent of all Users whose personal
and transactional details will be accessible by other Users as a result of HICAPS approving this Request and have complied with all applicable
laws in doing so;
3.agree to indemnify HICAPS for all loss or damage HICAPS suffers or incurs as a result of my/our submitting this Request to HICAPS for its
consideration; and
4. acknowledge and agree that except where the contrary intention appears, all capitalised terms in this Request have the same meaning
as in the HICAPS Accounts Online Terms of Use.
D
Authorised signatures
Practice owner/s must complete the details below and sign here.
SignatureName
Date
/ /
SignatureName
Date
/ /
If you are the owner of your practice but not the Settlement Account, then the Settlement Account owner/s must also complete the details below
and sign here.
SignatureName
Date
SignatureName
Date
/ /
/ /
HICAPS Accounts Online Functionality by User Access Level
Access level
Provider/s
transactions
View & download
Transactions for all
providers attached
to an account ID
View & download
Previous HICAPS
Statements &
Daily Totals –
View & download.
Manage statement
frequency, type &
method (mail/e-mail)
Request to add
new providers to
HICAPS database
system*
Level 3
✓
✓
✓
✓
Level 2
✓
✓
✓
✓
Level 1
✓
Create and
upgrade additional
HICAPS
Modify Details
(mailing address,
e-mail etc)
Accounts Online
Users & ID’s
Own user details
✓
✓
✓
✓
Medicare Australia or Medibank Private letter required.
PLEASE NOTE: This table is correct at the time of printing. However, over time, HICAPS Accounts Online functionality will be extended/enhanced.
HICAPS Pty Ltd A.B.N. 11 080 688 866
A wholly owned subsidiary of National Australia Bank Ltd A.B.N. 12 004 044 937
82819A0611