Health Insurance (Application For Acceptance Of Approved Pathology Authority Undertaking) Determination 2002 (HS/14/2002) (Cth)

Health Insurance (Application For Acceptance Of Approved Pathology Authority Undertaking) Determination 2002

HS/14/2002

I, KAY CHRISTINE LESLEY PATTERSON, Minister for Health and Ageing, determine the particulars contained in the attached form, and approve that form, for the purposes of subsection 23DF(2) of the Health Insurance Act 1973.

This Determination commences on 1 January 2003 and revokes all previous determinations made under subsection 23DF(2) of the Health Insurance Act 1973.

Dated 13^th November 2002

Kay Patterson

Minister for Health and Ageing

Health Insurance Commission

Application for Acceptance as an Approved Pathology Authority

Section 23DF Health Insurance Act 1973

­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­ Applicant Details and Indication of Applicant Type (eg Body Corporate, Partnership)

­­APA Number – for renewal applications

Please tick a box and fill in corresponding  section

Body Corporate

Company Name

No.

Street Name

Suburb   State   Postcode

 

Registered Address

ABN Number

State Government, Territory Government or a public authority

Body Name

No.

Street Name

Suburb   State   Postcode

 

Registered Address

ABN

Partnership

Partnership Name

No.

Street Name

Suburb   State   Postcode

 

Registered Address

ABN

Natural Person

Persons Name

No.

Street Name

Suburb   State   Postcode

 

Street Address

ABN

Trading Name (If any - must be owned by the applicant)

Registered Name

          /           /

 

Registration expires

Contact Details for Applicant

Contact Person

Details as above

Address for Correspondence

No./PO Box

Street Name

Suburb   State   Postcode

 

Details as above

Contact Telephone Number            Mobile

(area code)

Fax Number

Email Address

by entering email address, you acknowledge that all notices may be given to you by email)

Please proceed to the question indicated for your Applicant Type:

Body Corporate   Go to question 1

Partnership   Go to question 2

State Government, Territory Government or public authority      Go to question 3

Natural Person   Go to question 3

1.         Body Corporate

NOTE: The form for this question can be copied and the extra page/s attached to the application where the space is insufficient (eg. a partnership of a number of companies).

(a)        List Directors – if a sole director company, please indicate

1	6
2	7
3	8
4	9
5	10

(b)        Names and positions held by Principal Office Bearers of the Applicant (eg.Manager, Executive Director).

Name	Title of Office held
1
2
3
4
5

(c)        Names of Principal Shareholders (top 10) in order of shareholding.

Principal Shareholders at date of application	Approx % of Shareholding at date of application
1	%
2	%
3	%
4	%
5	%
6	%
7	%
8	%
9	%
10	%

Go to Question 3

1. Partnership

Please detail each partner.

Natural Persons/Body Corporate Partners	Percentage Share of Partnership	ABN if applicable
%
%
%
%
%
%
%
%
%
%

Go to Question 3

1. Is the applicant or, to the applicant’s knowledge (having made reasonable enquiry), any person with whom the applicant has or proposes to have a financial, employee/employer or business relationship, a person:

a)to whom notice has been given under subsection 23DL(1) or                   Yes    No

23DM(1) of the Act or in relation to whom notice has been given

to a Chairperson of a Medicare Participation Review Committee

under subsections 23DL(4), 23DM(4) or 124D(2) of the Act?

b)to whom notice has been given under subsection 124FA(3) or                   Yes   No

124FE(3) of the Act?

c)

in relation to whom a Medicare Participation Review Committee

has made a determination under section 124F, 124FB, 124FC   Yes   No

or 124FF of the Act?

  

d)to whom notice has been given under subsection 102(1) of    Yes   No

the Act?

e)to whom a final determination under section 106T of the Act Yes No

has been made?

f)             who has been convicted of a relevant offence as defined in   Yes   No

s23DA of the Act?

If you have answered ‘Yes’ to question 3 (a,b,c,d, e, or f), please provide details.

Details should consist of Name, Company Name and Provider Number if applicable.

 

*Note: ‘reasonable enquiry’:- You will be required to provide some information about another person when making your application. Reasonable Inquiry means that, unless you are certain of the situation, you will be expected to ask the person involved to ensure that your answer is as accurate as can reasonably be expected. You will not be expected to make exhaustive investigations. If you are unsure about a certain response you should seek clarification from the Health Insurance Commission.

1. Additional information

Please attach any additional information if required.