Provider Registration

To continue please validate your Medical Council Registration Number and Speciality

Medical Council Registration Number

Speciality

Title

First Name

Last Name

Mobile number

Please use format 087 1234567

Please provide your active Irish Tax Reference Number (TRN) so that we can pay the PSWT on your behalf

Kindly select and provide one of the following tax types associated with your TRN

Bank Name

Bank Address

Bank Account Name

IBAN

Please use format IE29AIBK93115212345678

Practices

You can add the details of your practice/s below or continue if you don't have a practice

Hospitals

You can add the details of your hospital/s below or continue if you don't have a hospital

1. Speciality

Medical Council Registration Number:
Speciality:

2. Personal

Title:
First Name:
Last Name:
Mobile number:
Email:

3. Financial

Please provide your active Irish Tax Reference Number (TRN) so that we can pay the PSWT on your behalf:
Kindly select and provide one of the following tax types associated with your TRN:
Bank Name:
Bank Address:
Bank Account Name:
IBAN:

4. Practices

No practice details

5. Hospitals

No hospital details

Are you opting to be a:

Participating Consultant Part-Participating Consultant

Data Protection

Level Health is registered with the Office of the Data Protection Commissioner to act as a data controller and data processor in relation to the information you provide about yourself. The information you have provided will be used to administer and pay claims and for the operation of anti-fraud policies on financial services provided by us. We will share this information with our third party administrators and any other commercial entity for the purposes above and as required to provide our services and in order to comply with legal obligations imposed on us. We may share and use this information both inside and outside of the European Economic Area, in confidence, for these purposes. You have a right (subject to applicable data protection legislation) to obtain a copy of the personal information we hold about you. In order to obtain a copy of such information, please contact Level Health through the provider portal. Should you discover any errors or omissions in the personal information held by us, you may have the right to have such errors corrected, blocked or erased, please contact us to action same.

Declaration

I/we confirm that all the details, answers and information given in this form are true, accurate and complete. I understand that the information will be used to process the claim as outlined above and for the purposes as set out in the Level Health privacy notice which can be found on our website.

Consultant Name

Date

Thank you for registering with Level Health

We will follow up with an email to complete the final steps in the process