MSP Portal REGISTRATION application

and

banking details FORM

/

EMAIL completed form TO

healthcare Provider personal DETAILS

*Surname
*Name/s
ID No. / Title
*Professional Council Number

Medical practice details

*Practice Name
*Practice No.
Discipline Type
*VAT No.

healthcare provider BANKING DETAILS

*Bank Name
*Branch Code / *Account Type
*Account Number
*Account Holder
*Confirmation of Banking Details Attached
(tick applicable) / Official bank letter confirming account details – with bank stamp / Copy of bank account statement – with bank stamp

user contact DETAILS

*Surname
*Name/s
ID No. / Title
*Tel (w) / Cell
*Email
*Business Physical Address / Business Postal Address
Code / Code

Declaration by Healthcare provider

*I …………………………………………………………………………declare that the information contained herein is true and correct.
*Signature / *Date
Note: Please ensure that you have completed all fields with a “*”

FOR RMA OFFICE USE ONLY

*Practice telephone number
*Date / *Time
*Name of MPS Representative
*Name of RMA Representative conducting confirmation
*Signature of RMA Representative conducting confirmation
*Name of CPS Manager
*Signature of CPS Manager
Note: This page (pg 2) is to be scanned and indexed to the system.

pg. 2