Request to register for MediGap

or update details

Find out more information regarding MediGap and how

submitted details are used

This form provides nib Health Funds with information to allow your participation in MediGap or to update details of an existing account. Fields marked with an asterisk (*) are required.

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Provider Details

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Title *

First Name *

Last Name *

Provider Number(s) *Enter a single provider number or multiple separated by a comma.

Medical Specialty *Pathologists, radiologists and salaried practitioners at public hospitals are not eligible to participate in MediGap

Where do customers visit you?

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Practice Address

Suburb *

Postcode *

State *

Practice Phone

Practice Email

Practice Website

How can nib contact you?

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Title *

First Name *

Last Name *

Job Role *

Street Address *

Suburb *

Postcode *

State *

Phone *

Contact Email *

Banking Details

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BSB *

Account Number *

Account Name *

Authorisation

Please acknowledge that you are the provider listed above or have authorisation from that provider to submit this form.

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