Doctor Contact Request
Your Name
*
Billed or unbilled query
*
Billed
Unbilled
Invoice Number
*
Billing File Number
*
Provider
Name
First
Last
Group or Personal
*
Group
Personal
Group
*
--select--
ACCG
CCIWA
Darwin Paeds
ECCG
Gastrocare
Macquarie Group
Macquarie Heart Group - Chatswood
Macquarie Heart Group - Dee Why
MICS
MNCH
MOG
MSDC
NT Cardiac
NTMS
OHC
SBC
SCCG
SDA
SMTS
SSIC
Tankard Medical
WIC
Patient
Name
*
First
Last
Date of Birth
*
Day
Month
Year
Billing
Hospital
Check this box if date of service is unknown
Yes
Date of Service
*
DD slash MM slash YYYY
Query
Query Type
*
Referral
Item Number/s
Fees
Enquiry
*
Please word your query as though you are writing an email.
Name
This field is for validation purposes and should be left unchanged.