An application for internal review under section 191 of the Law must include the following information--
(a) the name of the applicant;
(b) contact details for the applicant, including an address for service of the decision;
(c) the provider approval number or service approval number to which the reviewable decision relates;
(d) the full name of the person to whom the provider approval or service approval was granted;
(e) a statement setting out--(i) the details of the decision or the part of the decision with respect to which review is sought;(ii) how the decision affects the applicant;(iii) the grounds for seeking a review of the decision;
(f) any information that the applicant considers relevant to the review.