E-Business Professionals Exercise
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1 CHANGES REGISTER PERSONAL INFORMATION Member Name: Your Signature: CHANGE OF NAME Former Name: CHANGE OF Former CHANGE OF MOBILE NUMBER Former Mobile Number: CHANGE OF HOME LANDLINE Former Number: CHANGE OF HOME ADDRESS Former Address: CHANGE OF POSTAL ADDRESS Former Postal Address: PO Box: Member Number: Today s Date: New Name: New New Mobile Number: New Number: New Address: New Postal Address: PO Box: Suburb State P/C P/C Page 1 of 6
2 CHANGES REGISTER BUSINESS INFORMATION Member Name: Your Signature: CHANGE OF BUSINESS NAME Former Business Name Former Business ABN: Member Number: Today s Date: New Business Name: New Business ABN: Medibank Private maximum of 3 locations Former Practice 1: New Practice 1: Provider Number: Former Practice 2: New Practice 2: Provider Number: Continued on Page 3 Page 2 of 6
3 CHANGES REGISTER Continued from Page 2 Medibank Private Former Practice 3: New Practice 3: Provider Number: Do you want the changes for Medibank Private to be applied to all Health Funds? YES NO (Medibank only) All Other Health Funds multiple locations P/C Send a copy of Change Notification to MAA Save a copy of Change Notification to your Business Files Office@maa.org,au Post: PO Box 2019, MOORABBIN VIC 3189 Fax: (03) Continued on Page 4 Page 3 of 6
4 CHANGES REGISTER Continued from Page 3 All Other Health Funds multiple locations Page 4 of 6
5 CHANGES REGISTER Continued from Page 4 All Other Health Funds multiple locations CHANGE OF INSURANCE COMPANY Former Insurance Company: New Insurance Company: CHANGE OF STATUS Retired: Close all practices No longer Practicing: Close all practices On Leave: From: Note: If for longer than 12 weeks, all locations To: will be closed Moving to another Association YES Note: When moving to another Association before your Membership expires your Provider Numbers can travel with you Page 5 of 6
6 CHANGES REGISTER MAA OFFICE USE ONLY Date Change Received: DATE DATABASE UPDATED PERSON RESPONSIBLE DATE HF REPORT UPDATED PERSON RESPONSIBLE AHM AUSTRALIAN UNITY ARHG BUPA CBHS GRAND UNITED HBF HCF / MANCHESTER UNITY HEALTH PARTNERS MEDIBANK NIB Date all entries completed: Date filed in Members hard copy file: Person Responsible for final filing: Page 6 of 6
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