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 13th 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
Registered Address
ABN Number
State Government, Territory Government or a public authority
Body Name
Registered Address
ABN
Partnership
Partnership Name
Registered Address
ABN
Natural Person
Persons Name
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
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
2. Partnership
Please detail each partner.
Natural Persons/Body Corporate Partners | Percentage Share of Partnership | ABN if applicable |
| % |
|
| % |
|
| % |
|
| % |
|
| % |
|
| % |
|
| % |
|
| % |
|
| % |
|
| % |
|
Go to Question 3
3. 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.
4. Additional information
Please attach any additional information if required.