MICS Request
Request type
*
- - Select One - -
Create an invoice
Adjust an invoice
Investigate
Provider
*
- - Select One - -
Tristan Yan
Christopher Cao
Brian Plunkett
Hospital
*
- - Select One - -
Sydney Adventist Hospital
Chris O'Brien Lifehouse
Macquarie University Private Hospital
Strathfield Private Hospital
Royal Prince Alfred
Concord Repatriation General Hospital
Patient name
*
Patient Number
*
Invoice number
*
Date of service
*
DD slash MM slash YYYY
Item numbers
*
Billing instruction
*
- - Select One - -
Known gap
Private fee
Discounted private fee
No gap
Other
Discount instruction
*
Billing instruction
*
Document
Drop files here or
Select files
Accepted file types: jpg, bmp, png, pdf, xlsx, docx, Max. file size: 50 MB, Max. files: 5.
Name
This field is for validation purposes and should be left unchanged.