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Fill in the form below to register your clinic on MBS@Gov.


MBS Online Application Form
 
General Practitioner Dialysis Centre
 
HCI (MOH Healthcare Institution Code) * :
UEN * :
Licence No * :
Licence Begin Date * : (dd/mm/yyyy)
Licence End Date * : (dd/mm/yyyy)
MOH Licence Softcopy * :
 
 
Clinic Name * :
Clinic Name (Cont'd, if applicable) :
Doctor's Name * :
Clinic Address * :
Postal Code * :
Country : Singapore
 
Email Address * :
Telephone No * :
GST Registration * :
Note: Bank Verification Banks include DBS, UOB, OCBC and Citibank. Please select "No" if your bank account is not from any of the Bank verification Banks
Bank Verification by MBS@Gov system * :
Bank Code and Name * :
Branch Code and Name * :
Bank Account No * :
UEN (Registered with Bank Account) * :
 
Note : Fields marked as * are mandatory to be filled
(a) I/We hereby authorise the Government and Statutory Boards to credit payments due to me/us to the above account. Amounts so credited would constitute valid discharge of obligations due to me/us.

(b) This authorisation shall continue to be in force until I/we have notified you in writing.

(c) I/We hereby request and authorise the Government and Statutory Boards to obtain confirmation/verification of information relating to me/us and/or to my/our account(s) from/with the bank where the Account is maintained as stated in the form.

(d) In consideration of the Government and Statutory Boards acceding to my/our said request and in consideration the Bank confirming/verifying such information pursuant to the said request, I/we irrevocably consent to and authorise the Bank, including any officer thereof, to disclose any information whatsoever relating to me/us and to the Account as is necessary for the sole purpose of account validation and agree that such authorisation shall survive any termination of the Account. I/We agree that this consent shall survive the termination of any of the Account with the Bank and may be relied on and enforced as fully and effectively by the Bank as if it is addressed to the Bank.

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Updated as at 30 Sep 2019