Change of Details

Update your contact details (incl. name change)

Use this form to change your name, correspondence, phone, graduation date or other details.

Alternatively, you can change your contact details directly by logging in to My Membership. You are automatically registered for My Membership when you provide your email address, which you can access using your member number.

By providing your email address you consent to receive communication electronically.

Privacy

The information requested in this form is required by MIPS for its business operations. By completing this form you consent to the collection, use, storage and disclosure of any personal information as outlined in our Privacy Statement. These policies are consistent with the requirements of the Privacy Act and Australian Privacy Principles.

Eventid

LO initiated?

Yes No

e5classification

E5 classification: Change of details

e5classification

E5 classification: Change of details including practice state

Current personal details

Title*

First name/s*

Surname*

Date of birth*

Member number

Leave blank if you are unsure

I am signing on behalf of a member

If you are signing on behalf of a member you must provide either a copy of:

Guardianship papers or Power of Attorney.
Deceased member’s will and testament which appoints you as the personal legal representative.
MIPS delegation of authority form.

Supporting document*

No File Chosen

File uploads may not work on some mobile devices.

Only one document is required

Contact details of person acting on behalf of member

Title*

First name/s*

Surname*

Email*

Mobile*

Provide landline (including area code) if no mobile

What would you like to update?

Phone or email address*

Yes No

Correspondence address or practice location*

Yes No

Name or title*

Yes No

Study Details*

Yes No

Completion date or education provider

You have chosen no for all four change of details options. You do not need to continue with this form.

New correspondence address or practice location

Correspondence address*

I am unable to find my address

Country*

Address line 1*

Address line 2

Suburb/locality*

State/Province*

Postal/zip code

Do you also need to update your practice location?*

Yes No

Changing your primary practice state may result in an amendment to your membership fee, especially if you are in private practice. MIPS will contact you to advise if a refund or additional payment is due.

Primary place of employment (or employer)

Please specify (primary place of employment)

Primary practice suburb/locality*

The location you undertake the majority of your work or billings. If you work in multiple locations, provide the capital city of the state you work the majority of the time. Find out more

Primary practice state

Primary practice postcode

Effective date practice state changed*

Date you commenced or will commence practicing in the primary practice state

New phone or email address

Primary email*

Alternative email

Mobile*

Provide landline (including area code) if no mobile

New study details

Expected date of completion of healthcare qualification*

This can be approximate

University or education provider*

University or education provider (other)*

Select the discipline you will practice when you complete your studies

Field of study*

New name or title

Title*

First name/s*

Surname*

Reason for change

Spelling mistake Deed poll Marriage Reverting to maiden name

Other:

Supporting documentation

No File Chosen

File uploads may not work on some mobile devices.

Unless you are correcting a spelling error in your name, you must provide evidence of a change to your name or date of birth, regardless of whether you do this on behalf of a member.

Confirmation

I confirm the details I have provided in the previous pages are true and I accept that this information will be used in accordance with the MIPS Privacy Statement.

Confirm