Health and service provider registration form

To register as a TAC health or service provider, please check our registration requirements, then complete the form below.

You do not need to complete this form if:

You are a disability service provider – please visit our disability services registration page.
You are interested in undertaking independent medical examinations for the TAC – please contact us at medical_examiners@tac.vic.gov.au
You have already registered as a TAC provider and need to update your bank details – please use our Update provider bank details form.

Provider details

Is this updating a business that is already registered with TAC ? eg business is purchased/sold, new trading name, new ABN etc

Please provide previous business details

First Name *

Last Name *

Provider type *

Company Name (if payable to the company)

ABN

Telephone number *

Email Address *

Fax number

Additional information

File upload (Please upload any information relevant to your registration, certificates etc if required )

Service Location

Service location address *

Service Location Suburb/City *

State *

Postcode * Service Postcode

Postal Address

Postal address is same as service location addres

Address Postal Address

Suburb/City Postal Suburb/City

State Postal State

Postcode Postal Postcode

Bank account details

Name of bank or financial institution *

BSB number * (no spaces)

Account number * (no spaces)

Name/s of account holder

Name of Account

Your privacy

The TAC will use this information in accordance with the Privacy and Data Protection Act 2014. We will use this information to register you as a TAC provider for the first time. We will use your bank account details to make EFT payments to you. We may use this information to contact you, provide general TAC news and information and for reasonable secondary purposes.

For more information, please see our Privacy policy.

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.