Update provider bank details

• Complete the form below to update the bank details you have registered with the TAC
• As a security measure you will be asked to provide your current bank details
• To update a joint account we need the names of both account holders

Provider details

First name *

Last name *

Company name (if invoices payable to a company)

Email *

Phone *

Fax number (if applicable)

Medicare provider number (if applicable)

Service location address *

Service location suburb *

Service location Postcode *

Postal address (if different to service location)

Postal Suburb (if different to service location)

Postal postcode (if different to service location) (if different to service location)

New bank details

Name of bank or financial institution *

How many account holders are there? *

-- Please Select --12

Name of account holder 1 *

Signature of account holder 1 *

Name of account holder 2

Signature of account holder 2

Name of account *

BSB *

Account number *

Most recent payment

As a security measure, please provide details of the most recent payment you have received from the TAC.

Date

Amount

Description of payment received

Declaration

Disclaimer *

• I declare that the details I have provided on this form are true and correct. I understand that it is an offence under the legislation to provide false or misleading information.

Your signature *

Printed name of person submitting form

Position held in the business

Date

Your privacy

The TAC will use this information in accordance with the Privacy and Data Protection Act 2014. Without this information, we will not be able to make EFT payments to you.

For more information, please see our Privacy policy.