Health Fund Clinic Details Δ This field is hidden when viewing the formSection BreakDo you want your provider details published on Health Fund websites No (Keep my provider details private) Yes (Publish my provider details) This field is hidden when viewing the formSection BreakClinic 1 - Street Address (NO business name)(Required)Street Name and number. e.g, 77 Fortitude AvenueClinic 1 - Business Name / Unit / Level (optional)You can put your business name here, or tricky address. e.g. Unit 7, level 34Clinic 1 - Suburb(Required)Clinic 1 - State(Required)ACTNSWNTQLDSATASVICWAClinic 1 - Postcode(Required)Is your Clinic a home-based clinic?(Required) Yes No Do you practice at a second clinic location?(Required) Yes No Clinic 2 - Street Address (NO business name)(Required)Street Name and number. e.g, 77 Fortitude AvenueClinic 2 - Business Name / Unit / Level (optional)You can put your business name here, or tricky address. e.g. Unit 7, level 34Clinic 2 - Suburb(Required)Clinic 2 - State(Required)ACTNSWNTQLDSATASVICWAClinic 2 - Postcode(Required)Do you practice at a third clinic location?(Required) Yes No Clinic 3 - Street Address (NO business name)(Required)Street Name and number. e.g, 77 Fortitude AvenueClinic 3 - Business Name / Unit / Level (optional)You can put your business name here, or tricky address. e.g. Unit 7, level 34Clinic 3 - Suburb(Required)Clinic 3 - State(Required)ACTNSWNTQLDSATASVICWAClinic 3 - Postcode(Required)Do you practice at a fourth clinic location?(Required) Yes No Clinic 4 - Street Address (NO business name)(Required)Street Name and number. e.g, 77 Fortitude AvenueClinic 4 - Business Name / Unit / Level (optional)You can put your business name here, or tricky address. e.g. Unit 7, level 34Clinic 4 - Suburb(Required)Clinic 4 - State(Required)ACTNSWNTQLDSATASVICWAClinic 4 - Postcode(Required)
