Ambulance Levy Registration

The Ambulance levy is payable by private health insurance companies carrying out business in the ACT.  Private health insurers are required to register with the Commissioner for ACT Revenue.

Please complete the following form to register your company for the Ambulance levy with the ACT Revenue Office. All fields marked ( * ) are mandatory.

Company details











Does this business have a myGovID? *

Contact Details









Ambulance levy details




If you are already registered with the ACT Revenue Office for a tax or duty, please provide the client number
previously supplied by this office.

Date services commenced? *

Directors

List all directors, legal entity secretaries and officers showing full names, title and address






Declaration


  • Declare that the information provided in this registration application is true and correct at the time of application.
  • I acknowledge that under section 338 of the Criminal Code 2002, giving false or misleading information is a serious offence and I will notify the ACT Revenue Office in writing and provide full details if there is a change in my circumstances during the financial year. This includes change of contact details, address or cessation of trading in the ACT.

Privacy Statement

Information collected by the ACT Revenue Office (ACTRO) is protected by secrecy provisions contained in Acts administered by the ACTRO, including the Taxation Administration Act 1999, and is used for the purposes of administering those Acts. In addition, personal information provided to the ACTRO is protected by the Information Privacy Act 2014. Information (including personal information) is not disclosed to any third party without the consent of the person involved, unless authorised by law. For example, the ACTRO may disclose tax information in connection with the administration of a tax law, or may be required to disclose information to organisations that have legal authority to require the information in prescribed circumstances, including for law enforcement purposes.

Please read our Privacy Policy which sets out how personal information is collected, used and disclosed by the Commissioner for ACT Revenue and the ACT Revenue Office, how you may access and seek correction of your personal information, and how you may complain about breaches of privacy.