ACCREDITATION FORM SCHEDULE 5

Transcription

1 ACCREDITATION FORM SCHEDULE 5 APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER Please submit completed application form to the General Manager at your Healthscope Limited Hospital. Application may be made for Accreditation at more than one Healthscope Hospital on this form. Applications for Accreditation at more than one Healthscope Limited Hospital will be copied and forwarded to the relevant General Manager at each hospital for separate and independent consideration. Please list the Hospitals to which you wish this form to be forwarded. To the General Manager, Allamanda Private Hospital, 21 Spendelove Street, SOUTHPORT QLD 4215 Please copy and forward this application and supporting documents for Accreditation to the following additional Hospital(s) for consideration: Name of additional Hospital(s): 1. Initial Accreditation / Renewal of Accreditation 2. Initial Accreditation / Renewal of Accreditation 3. Initial Accreditation / Renewal of Accreditation 4. Initial Accreditation / Renewal of Accreditation Contact Name Title: DR MR MISS A/PROF PROF OTHER: (please specify) Date of Birth: Surname of Applicant: First Name in full: Contact Addresses (please indicate which is preferred for correspondence) Residential Address: Tick here if preferred address for correspondence: Street: Suburb: State: Post Code: Home Telephone: Professional Address (Primary Consulting Rooms): Home Fax: Tick here if preferred address for correspondence: Street: Suburb: State: Post Code: Rooms Telephone: Rooms Fax: Pager Telephone: Pager Number: Mobile Number: Address: Provider Number: For renewal of accreditation: If this is an application for renewal of accreditation only and there are no changes to the information required as advised by the General Manager, you are required to indicate by ticking the Renewal of Accreditation Only box below, and sign this application in the space provided. Renewal of Accreditation Only no further information required Signature of Applicant Date 1

2 Please attach Curriculum Vitae with details of: Undergraduate Qualifications, University, Year of Graduation Postgraduate Qualifications, Degrees, Diplomas, Fellowships (including awarding body, qualification and year obtained) Hospital appointments within the last 5 years (dates, hospitals, positions held) Ongoing postgraduate education/cpd in the past 3 years Publications SCOPE OF PRACTICE You must tick the specialty and then all sub-specialties for which you are seeking accreditation: ADDICTION MEDICINE ANAESTHESIA Obstetric (>1 year old) Cardiac CARDIOLOGY Diagnostic procedures Interventional procedures Electrophysiology studies Implantable electronic devices Other, e.g. Valvuloplasty, PFO/ASD Closure CARDIOTHORACIC SURGERY Valvular Procedures Coronary Artery Bypass Arrhythmia Surgery Thoracic Aorta Procedures Thoracic/Lung Procedures Insertion of Pacemaker DENTAL General Dentistry Oral Surgery Oral and Maxillofacial Surgery Special Needs Dentistry DERMATOLOGY EMERGENCY MEDICINE ENT SURGERY Adenoidectomy Bronchial Procedures Ear Procedures Facial Nerve Laryngeal Procedures Nasal Procedures Otolaryngology Head & Neck Pharyngeal Procedures Tonsillectomy Tracheal Procedures GASTROENTEROLOGY Diagnostic Upper Gastrointestinal Endoscopy Therapeutic Upper Gastrointestinal Endoscopy Sclerotherapy Oesophageal Banding & Placement of Oesophageal Prostheses Oesophageal Dilation Flexible Sigmoidoscopy Diagnostic Colonoscopy Therapeutic Colonoscopy Endoscopic Retrograde Cholangiopancreatography (ERCP) & associated therapeutic interventions Biliary Stenting Percutaneous Endoscopic Gastronomy (PEG) GENERAL PRACTICE Non-procedural GP Anaesthetics GP Obstetrics GP Surgical GENERAL SURGERY Obesity Lap Banding Modified Roux-en-Y Sleeve Gastrectomy Breast Surgery Colorectal Surgery Endocrine Surgery Adrenalectomy Thyroidectomy Endoscopic Surgery Gastrointenstinal Surgery Hepatobiliary & Pancreatic Surgery Laparoscopic Surgery Diagnostic Interventional Oesophagectomy Sentinel Node Biopsy Upper GI Surgery GYNAECOLOGY Advanced Endoscopic Surgery Gynaecology General Prolapse Surgery Ultrasound Assisted Reproductive Services (IVF) Gynaecological Oncology Uro-Gynaecology INTENSIVE CARE MEDICINE INTERNAL MEDICINE Clinical Genetics Clinical Pharmacology Endocrinology Geriatric Medicine Haematology Hepatology Immunology & Allergy Infectious Diseases Medical Oncology Nephrology Neurology Nuclear Medicine Radiation Oncology Respiratory Medicine Bronchoscopy - Diagnostic Bronchoscopy - Therapeutic Sleep Medicine Rheumatology NEUROSURGERY Nerve Procedures Spinal Procedures Intracranial Procedures OTHER HEALTH PRACTITIONER, please specify: OBSTETRICS Maternal Fetal Medicine Obstetrics Ultrasound OCCUPATIONAL AND ENVIRONMENTAL MEDICINE OPHTHALMOLOGY Cataract Surgery Corneal Transplantation Eyelid Surgery Glaucoma Surgery Lacrimal Surgery Oculoplastic Surgery Orbital Surgery Pterygium Surgery Refractive Surgery Squint Surgery Vitreoretinal Surgery ORAL & MAXILLOFACIAL SURGERY Maxillofacial Surgery Mandibular Osteotomy 2

3 ORTHOPAEDIC SURGERY Arthroscopy Fracture Management Major Joint Replacement Reconstructive Surgery Spinal Surgery PAEDIATRIC MEDICINE General Medicine Neonatology Level II (34 weeks or later) PAEDIATRIC SURGERY PAIN MEDICINE PALLIATIVE MEDICINE PATHOLOGY Anatomical/Cytopathology Biochemistry Chemical Pathology General Pathology Haematology Immunology Microbiology PLASTIC & RECONSTRUCTIVE SURGERY Otoplasty Repair of Lacerations Revision of Scars Abdominal Reductions Breast Augmentation Breast Reduction Cosmetic Rhinoplasty Brow Surgery Facial Surgery Gender Reassignment Laser Ablation Liposuction Neurovascular Flaps PSYCHIATRY General Adolescent Psychogeriatric ECT TMS RADIATION ONCOLOGY RADIOLOGY Diagnostic Radiology Diagnostic Ultrasound Nuclear Medicine REHABILITATION MEDICINE SURGICAL ASSISTANT UROLOGY GENERAL Endoscopic Urology Laparoscopic Urology Laser Open Urological Procedures Brachytherapy HiFU Lithotripsy VASCULAR SURGERY Anastomosis Arterial Patch Bypass Decompression Embolectomy Endarterectomy Ligation of Aneurysms Repair Replacement Thrombectomy Vascular Trauma Abdominal Aortic Mesenteric Open Axillary, Subclavian Carotid Surgery Open Femoral Iliac Jugular Renal Temporal Thoracic REGISTERED HEALTH PRACTITIONER (NON-MEDICAL) Aboriginal & Torres Strait Islander Health Practitioner Chinese Medicine Practitioner Medical Radiation Practitioner Occupational Therapist Chiropractor Dental Practitioner Nurse / Midwife Optometrist Osteopath Pharmacist Physiotherapist Podiatrist Psychologist For Surgical Assistant applicants only: Name of accredited Health Professional at each applicable Hospital who will provide a reference for you. (Attach document if insufficient space) Contact Number: Hospital: Accreditation Sought (Please Tick): Permanent Temporary Specified Dates: 3

4 Please provide the contact details of two referees who are practitioners within the intended specialty or sub-specialty in Australia who can attest to your recent clinical practice and who are not related to you nor financially linked with or financially dependent on you (Not applicable to surgical assistants). Name of Referee 1: Name of Referee 2: Contact Details (telephone / ): Contact Details (telephone / ): Registered health practitioners please provide your current AHPRA registration number: Are there any conditions attached to this registration? Yes No If yes, provide details of conditions: Please state the name of your medical defence organisation or your professional indemnity insurance provider and provide photocopy: Membership Number: Category of membership (insert specialty; for example Full Surgeon ): Does your membership fully cover the scope of practice you have applied for? Yes No 4

5 Has your Scope of Practice (clinical privileges) and/or accreditation at any hospital or day procedure centre ever been reduced, suspended or revoked or have you had conditions attached to that appointment for any reason? Yes No If yes, give dates and particulars: Medical Practitioners Only - Please nominate two medical practitioners accredited at the Hospital in your specialty available for contact by the Hospital in case of an emergency if you are unavailable: Specialty: Specialty: Listing of Health Practitioners: (not applicable to surgical assistants) I authorise the Hospital(s) to include my details in any listing of Health Practitioners Yes No Authority: I hereby apply for accreditation at the hospital(s) I have specified with the Scope of Practice (clinical privileges) I have also specified. I authorise my medical indemnity insurer to provide a Certificate of Currency or equivalent including details of my medical indemnity insurance cover to the Hospital. In making this application I acknowledge and agree: - I have received a copy of the Healthscope Limited Hospital By-Laws (please initial) - I will abide by the By-Laws (please initial) - The Hospital(s) General Manager(s), its officers and the Medical Advisory Committee(s) or its/their Credentials Committee may seek information about my past experience, clinical performance and current fitness and current insurance/indemnity status. (please initial) Signature: Date: Check List please ensure that the following is forwarded to the Hospital: Completed Schedule 5 Curriculum Vitae Medical Indemnity Insurance Certificate of Currency or equivalent 5