IMPORTANT INFORMATION: This form is to be used when seeking approval to determine a new . If you require assistance in completing this form please contact the in the instance. Once completed please submit the form to the above email address. PART A APPLICANT DETAILS – Name: HE Number: Position: Department: Health Service: Contact Number: Officer Declaration: Name: I declare that the Signature: information provided on this Date: form is true and correct to the best of my knowledge PART B DESCRIPTION OF FEE OR CHARGE – Health Services Category of Fee or Charge: Other Goods and Services Reason for New Fee or Charge: Proposed Fee or Charge: $ Please attach the Costing Methodology used to determine the Fee or Charge as an Excel spreadsheet Level at Which Fee or Cost Recovery Charge will be set: Above Cost Recovery Below Cost recovery Please provide an explanation on Additional Information sheet if above or below cost recovery
IMPORTANT INFORMATION: This form is to be used when seeking approval to determine a new . If you require assistance in completing this form please contact the in the instance. Once completed please submit the form to the above email address. PART A – APPLICANT DETAILS Name: HE Number: Position: Department: Health Service: Contact Number: Officer Declaration: I declare that the information provided on this form is true and correct to the best of my knowledge Name: Signature: Date: PART B – DESCRIPTION OF FEE OR CHARGE Category of Fee or Charge: Health Services Other Goods and Services Reason for New Fee or Charge: Proposed Fee or Charge: Please attach the Costing Methodology used to determine the Fee or Charge as an Excel spreadsheet $ Level at Which Fee or Charge will be set: Cost Recovery Above Cost Recovery Below Cost recovery Please provide an explanation on Additional Information sheet if above or below cost recovery
Schedule-C-Application-Form-to-Determine-a-New-Fee-or-Charge.docx