Manual identity verification for Provider Digital Access

1 1 of 3 Purpose of this formComplete this form if you were unable to verify your identity and/or change of name documents online for the Australian Government Department of Human Services Provider Digital Access (PRODA) form cannot be processed until you have created a PRODA username and password online and have received your Registration Authority (RA) of IdentityCreating a PRODA account requires you to verify your identity using the following documentation: Commencement of identity document Use in the Community documentsIf your name differs between these documents you will also be required to provide a change of name attach the documents you were unable to verify online. These documents do not need to be certified, a copy will document can only be used once as either a Commencement of identity or Use in the Community legible, full official documentation can be accepted.

2 Extracts of documents, ceremonial and commemorative certificates, and low quality scanned/copied documents cannot be more informationFor more information about PRODA, go to For assistance completing this form National Disability Insurance Scheme (NDIS) providers call 1800 800 110 Monday to Friday, between am and pm, Australian Eastern Standard Time. all other services call 1800 700 199 Monday to Friday, between am and pm, Australian Eastern Standard : Call charges may your formCheck that all required questions are answered and that the form is signed and dated by the account and email this form and relevant identity documents child care Provider personnel, email this form identity verification for Provider Digital AccessAccepted documents Change of name documents Change of name documents are only required if you have legally changed your name and documents are required to have security features from Births, Deaths and Marriages (BDM).

3 Marriage certificate (ceremonial certificates are not accepted) Change of name certificate Amended Australian birth certificate Commencement of identity documents Choose one of the following required documents. Australian passport Australian birth certificate (extracts and commemorative certificates are not accepted) Australian citizenship certificate (front and back) Foreign passport (with an Australian immigration visa linked) Certificate of registration by descent ImmiCardUse in the Community documents Choose 2 of the following documents, one is required to be from the primary documents list. This document must differ from previous Commencement of identity documents chosen. Primary documents Current Australian driver licence ImmiCard Australian passport Foreign passport (with an Australian immigration visa linked) Australian Government issued proof of age card/photo card Australian secondary student document (issued by a government agency or Australian school only) Secondary documents Medicare card Department of Foreign Affairs and Trade (DFAT) issued Certificate of identity DFAT issued Document of identity DFAT issued United Nations convention travel document Foreign government issued documents ( driver licence) Enrolment with the Australian Electoral Commission Security Guard/Crowd control photo licence Evidence of right to a government benefit (Department of Veterans Affairs (DVA) or Centrelink)

4 Consular photo identity card issued by DFAT Police force officer photo identity card Australian Defence Force photo identity card Commonwealth or state/territory government photo identity card Aviation security identification card Maritime security identification card Firearms licence Credit reference check Australian tertiary student photo identity document Australian secondary student photo identity document Certified academic transcript from an Australian university Bank/Credit card (front and back) 2 of 3 Service accessThis form cannot be processed until you have created a PRODA username and password online and have received your Registration Authority (RA) number. For more information, go to Which of the following will you use your PRODA account to Access : Health Professional Online Services (HPOS) Go to 2 National Disability Insurance Scheme (NDIS) Go to 3 Child Care Subsidy (CCS) Go to 3 Other Give details Go to 32 Do you have existing records and identifiers held by us ( MED00001300004)?

5 No Yes List your existing numbersApplicant s details 3 Family nameFirst given nameSecond given name4 Gender Male Female Indeterminate 5 Date of birth / /6 Mobile phone number7 Email address@8 PRODA account username9 PRODA RA numberAdditional identity verification documents10 How many documents have you attached to this form that could not be verified online?Number of Commencement of identity documentsNumber of Use in the Community documentsNumber of change of name documents (if your name differs between documents)Purpose of this form11 You are completing this form in order to: Complete the identity verification part of PRODA account creation Go to 13 Verify a change of name Change of name12 Enter any names which have been introduced by your identity documentation that differ from your PRODA account name (provided in question 3) and are listed on your change of name 1 Family nameFirst given nameSecond given nameName 2 Family nameFirst given nameSecond given nameManual identity verification for Provider Digital 3 of 3 Privacy notice13 Your personal information is protected by law (including the Privacy Act 1988 ) and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services.

6 This information is required to process your application or information may be used by the department, or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations).You can get more information about the way in which the department will manage your personal information, including our privacy policy, at s declaration14 I declare that: the information I have provided in this form is complete and understand that: giving false or misleading information is a serious offence. Applicant s signature-Date / /