COMPANY NAME TRADING NAME (IF DIFFERENT FROM ABOVE) ABN STREET ADDRESS SUBURB POST CODE POSTAL ADDRESS (IF DIFFERENT FROM ABOVE) SUBURB POST CODE HEALTH PROVIDER IDENTIFIER ORGANISATION NUMBER (HPI-O) PHONE FAX (please leave blank if you do not have a fax number) ORGANISATION EMAIL ADDRESS ORGANISATION TYPE ---Allied HealthCommunity HealthGeneral PracticeGovernmentHealth ServiceHospitalPathologyRadiologySpecialist PracticeSoftware VendorNot Sure / Other CLINICAL OR REPORTING SOFTWARE USED* ---MyHealthLink Portal (or No Capable System)Audit 4AUSLABBest Practice PremierBest Practice VIPEndoBaseCarestream RISCCOSCleverPsychClinic to CloudCommunicareCOMRADCoreplusDelphicEclaimsGE ViewPointGenie SolutionsGensolveGentuGPCompleteHealthTrackHELIXJAM SoftwareJhealthKarismaLabTrakMedical DatawareMedical DirectorMedical WizardMediflexMedilinkMedinetMediRecordsMedTech32MedTech EvolutionMMExMxSolutionsProfile for windowsPROMADIS MedicalProMedicusRx MedicalS4S Audit4ShexieSmartroomsSpecialist Practice ManagerStat HealthThe SpecialistTotalCareVisual OutcomesZedmedOther/Unsure OPERATING SYSTEM OF HOST WHERE HEALTHLINK WILL BE INSTALLED ---MAC OS X 10.7 LionMAC OS X 10.8 Mountain LionMAC OS X 10.9 MavericksMAC OS X 10.10 YosemiteMAC OS X 10.11 El CapitanMAC OS X 10.12 SierraMAC OS X 10.13 High SierraMAC OS X 10.14 MojaveMICROSOFT WINDOWS VISTA BUSINESSMICROSOFT WINDOWS 7 PROFESSIONALMICROSOFT WINDOWS 8 PROMICROSOFT WINDOWS 8.1 PROMICROSOFT WINDOWS 10 PROMICROSOFT WINDOWS SERVER 2008MICROSOFT WINDOWS SERVER 2008 R2MICROSOFT WINDOWS SMALL BUSINESS SERVER 2011MICROSOFT WINDOWS SERVER 2012MICROSOFT WINDOWS SERVER 2012 R2MICROSOFT WINDOWS SERVER 2016MICROSOFT WINDOWS SERVER 2019 DO YOU AGREE TO ABIDE BY THE HEALTHLINK TERMS AND CONDITIONS OF USE?* I agree on behalf of the Applicant that the Applicant will abide by the HealthLink Terms of Use and Master Service Agreement AUTHORISED REPRESENTATIVE NAME AUTHORISED REPRESENTATIVE PHONE AUTHORISED REPRESENTATIVE EMAIL AUTHORISED REPRESENTATIVE COMPANY POSITION OR TITLE* COMMENTS OR ADDITIONAL INFORMATION HOW MANY PROVIDERS DO YOU WISH TO REGISTER WITH YOUR ACCOUNT?* 123456789
TITLE DrMrMrsMsMxMissAssoc ProfProf FIRST NAME LAST NAME PROVIDER NUMBER (Please enter N/A if you do not have one) AHPRA MEDICAL REGISTRATION NUMBER SPECIALITY
TITLE DrMrMrsMsMissAssoc ProfProf FIRST NAME LAST NAME PROVIDER NUMBER (Please enter N/A if you do not have one) AHPRA MEDICAL REGISTRATION NUMBER SPECIALITY
TITLE DrMrMrsMxMsMissAssoc ProfProf FIRST NAME LAST NAME PROVIDER NUMBER (Please enter N/A if you do not have one) AHPRA MEDICAL REGISTRATION NUMBER SPECIALITY
TITLE DrMrMrsMsMxMissAssoc ProfProf FIRST NAME LAST NAME PROVIDER NUMBER* (Please enter N/A if you do not have one) AHPRA MEDICAL REGISTRATION NUMBER SPECIALITY
TITLE DrMrMrsMsMxMissAssoc ProfProf FIRST NAME LAST NAME PROVIDER NUMBER AHPRA MEDICAL REGISTRATION NUMBER
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