What it contains

Providers can complete this form to register with WorkSafe to provide services to injured workers. Information to be completed in the form includes:

  • service application type
  • applicant details, including practice, business or company details
  • banking details
  • provider registration requirements
  • applicant consent and declaration

Important: Please download this PDF to your computer. You can fill it in using Adobe Reader but it will not save if you attempt to fill it in using your web browser.

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