Submit ROI

Organisation Name (the legal entity which would contract with Brisbane North PHN)

* required

Maximum 255 characters

0/255

Business Name (if different to above)

Maximum 255 characters

0/255

ABN Number

* required

Maximum 255 characters

0/255

Business Address

* required

Maximum 255 characters

0/255

Suburb

* required

Maximum 255 characters

0/255

Postcode

* required

Maximum 255 characters

0/255

Business Phone Number

* required

Maximum 255 characters

0/255

Business Email

* required

Key Contact Name

* required

Maximum 255 characters

0/255

10.

Key Contact Email Address

* required

11.

Key Contact Phone Number

* required

Maximum 255 characters

0/255

12.

Name and street address of existing general practice, Aboriginal Community Controlled Health Service (ACCHS) or Community Health Centre where the proposed Medicare UCC will be based.

* required

13.

If intending to partner with an existing provider (as above) for the new Medicare Urgent Care Clinic, please provide the name and address of the partner.

* required

14.

Is the existing (or partnered) general practice, ACCHS or Community Health Centre accredited to a recognised and relevant standard such as the Royal Australian College of General Practitioner Standards for General Practice or other relevant standards such as the National Safety and Quality Health Service Standards, and the National Safety and Quality Primary and Community Healthcare Standards, or working towards accreditation to be achieved by 31 December 2025?

* required

Yes

15.

Please specify which Medicare Urgent Care Clinic funding you are interested in applying for. Note: Applicants seeking to register interest in applying for both locations must submit a separate ROI for each location.

* required

Narangba – Burpengary SA3 and bordering suburbs

Brisbane Inner SA3 (north of the Brisbane River) and bordering suburbs

16.

Any additional information relevant to your Registration of Interest for this funding.

17.

Upload any relevant supporting material (optional)