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.

This PDF is fillable. You can fill it out on your device, or print it and complete it by hand.

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: 5 November 2020