Common Contracts
1 similar Practitioners Licence Agreement contracts
PRACTITIONERS LICENCE AGREEMENTPractitioners Licence Agreement • November 22nd, 2013
Physical address:Street & No Postal address:PO Box Building Town/ City Town/ City Postal code Postal code or indicate if same as physical address Yes No Contact Person: Cell Tel Fax E-mail E-mail 2nd (for confidential Info)* PRACTICE MANAGEMENT SYSTEM INFORMATION (ACCOUNTING SOFTWARE)Package name Dealer / Sales Bureau name (if bureau services are utilised) CLAIMS SERVICES: Switching Method Preference. Please select ONE. MediSwitch Batch (QEDI) Yes No MediSwitch Online (SwitchOn) Yes No ELECTRONIC REMITTANCE ADVICES (“eRAs” – refer to clause 28) Yes No eRAs in PDF format (allows eRAs to be printed) which are provided at no cost Yes No eRAs in data format (which enables automatic reconciliation of payments if the PMA makes provision for such service) Yes No MARKETING INFORMATION Do you wish to receive marketing information about MediSwitch products?* Yes No Do you wish to receive marketing information about related products and companies?* Yes No Signed on behalf of the Practice b
