Provider Application

Submit your provider details for accreditation and administrative review.

Account Credentials

These details will be used to log in to the provider portal once your application is approved.

Facility Details

Tell us about your facility, what type of provider you are, and your regulatory identifiers.

Contact Information

Who should we contact regarding this application and for ongoing correspondence?

Banking Details

Provide bank accounts for claim payments. All fields on this step are optional — leave blank if not applicable.

USD Bank Account (United States Dollar)

Required for USD-denominated claim payments. Leave blank if you do not accept USD payments.

ZWG Bank Account (Zimbabwe Gold)

Required for ZWG-denominated claim payments. Leave blank if you do not accept ZWG payments.

Legacy banking fields (optional)
Banking notice: branch code auto-populates after selecting a bank and branch.

Required Documents

Please attach a clear scan or photo of each document (PDF, JPG or PNG). All marked items are required before your application can be submitted.

Review & Submit

Please review the details below before submitting your application.

Ready to submit? Once submitted, your application will be reviewed by our administration team. You will be notified by email once a decision has been made.
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