HealthSecure organisation registration form

Use this form to register your organisation for a digital certificate.

Sole practitioners, counsellors etc, must complete this application form to have your business registered with the New Zealand Health & Disability Sector Registration Authority (NZHSRA) for digital certificates.

ACC is acting on behalf of NZHSRA to process digital certificate applications for ACC and the Ministry of Health.

Prior approval required

Access to the Health Network must be approved by the Ministry of Health before we are able to proceed with this application. The Ministry of Health website provides further information and the necessary form to assist you.

How to join the Health Network

What you need to fill out this form

Your organisation’s contact details, including a named, main contact person.
Two named authorised signatories for your organisation (if applicable).
The vendor ID for the organisation (if applicable).

When you have all the relevant information, please allow around five minutes to enter it, as the form can’t be saved.

Need help?

If you need help to complete this form, please call NZHSRA.

Phone 0800 117 590.

Your privacy

When we collect, use and store information, we comply with the Privacy Act 2020 and the Health Information Privacy Code 2020. For more information read our privacy policy.

Our privacy framework

Complete the form below:

Organisation details

Organisation trading name:

Organisation legal name (if different):

Postal Line 1

Postal Line 2

Postal Line 3

Suburb

Region

City

Postcode

What is your application for?

ACC Electronic Transactions (eg. E-billing)

Ministry of Health - Health Network (e.g. NHI, NIR, Special Authority etc)

CareConnect

Organisation contact details

Name of the main organisation contact:

What is their job title?

What is their work phone number?

What is their mobile number?

What is their email?

Organisation declaration

Authorised signatories

Please supply names of authorised signatories for your organisation. These signatories can approve certificate requests on behalf of your organisation and revoke user certificates. You don't need to provide these if you are a sole practitioner.

Full name of signatory one:

Their job title:

Their work email address:

Their work phone number:

Full name of signatory two:

Their job title:

Their work email address:

Their work phone number:

Declaration

I declare that the information given in this form is true and correct, and that I authorise the NZHSRA (as the accredited Registration Authority) to verify this information.

I accept that the NZHSRA may decline any application or revoke any certificate at any time.

Your name:

Your job title:

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