Holter site checklist - thank you

Thank you. We look forward to partnering with you.

If a National AHC doctor will report for this site, please complete the following form to set up a new provider number.

Clinic name

Clinic contact name

First Name

Last Name

Clinic phone number

(###)

###

####

Site ID (minor ID)

(starts with 3 letters)

Bank account name

Bank account BSB

Bank account number

Business ABN