Provider Directory Data authorised recipient data release application or renewal form (MO003)

Use this form to seek authorisation for a contact person to access to data and receive correspondence in the Provider Directory System.

From February 2020, you’ll need an individual Provider Digital Access (PRODA) account when applying to be approved as an Authorised Recipient.

Download and complete the Provider Directory Data authorised recipient data release application or renewal form.

This form must be signed by the Chief Executive Officer or the Public Officer of an incorporated body, for example, Health Sector Entity Representative.

To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please contact us. We can help you access, complete and submit them.

Page last updated: 3 March 2022