Above Rate Service Agreement application form - TAC

Please use this form to apply for an Above Rate Service Agreement.

You can only complete this form if you are a registered TAC provider and are currently servicing TAC clients. If you are not currently servicing a TAC client your application will not be reviewed

Information collected on this form will help the TAC to make a decision on whether you are approved to charge the TAC above our scheduled fee.

Required fields are marked with an asterisk (*).

Service provider name *

Medicare provider number and suffix (if applicable)

Employer or company name *

ABN number *

Service Address *

Suburb *

Postcode *

Phone number *

Email address *

Service type *

If other, please specify

Please include the reason why you are requesting an above rate service agreement *

Do you invoice through HICAPS Digital Claims, paper or both *

HICAPS Digital Claims
Paper
Both

Please enter the items number and the requested rate you wish to claim.

Item number

Rate requested

Add 2nd item

2nd Item number

2nd Rate requested

Add 3rd item

3rd Item number

3rd Rate requested

Add 4th item

4th Item number

4th Requested rate

Add 5th item

5th Item number

5th Requested rate

If you have more than 5 items to request please upload a list

Please provide the full name and claim numbers of the TAC clients you currently provide services to.

1. Claim number *

1. Client name *

2. Claim number

2. Client name

3. Claim number

3. Client name

4. Claim number

4. Client name

5. Claim number

5. Client name

You certify that the information you are providing is true and accurate and that you have the authority to submit this form.

By completing this form you agree to treat TAC clients in line with the Clinical Framework for the Delivery of Health Services and that practitioners at your clinic will communicate, including via telephone, with the clinical panel as required and when requested in line with client privacy obligations.

Your privacy

The TAC needs this information in order to determine if we can pay you above the TAC fee schedule. We may use or disclose this information to assist in the ongoing management of the claim or any claim for common law damages. The TAC may also be required by law to disclose this information.

Without this information, the TAC may be unable to determine entitlements or assess whether treatment is reasonable and may not be able to approve further benefits and treatment.

If you require further information about our privacy policy, please call the TAC on 1300 654 329 or visit our privacy policy.