Hospital Accounting Services
56 Main Street,
Rathfarnham, Dublin 14
Telephone: 01 4928000
Local Rate: 1850 443 443
Email: customerservices@has.ie

Client Information Form

Please fill in the relevant information below and press submit, or you can download a printable version here and Post or Fax it to 01 4928040

Client Name:

Speciality:

Letters required after your name on bill heads

PPS number

Insurance Company Doctor Numbers

VHI:

Quinn Health:

Hibernian Health:

GMA:

Correspondence address:

Contact Number:

Contact Email Address:

Secretary's name (if applicable):

Phone:

Email:

Sort Code:

Account Number:

Please ensure that your E-Mail address is entered correctly.