Membership Application

Transcription

1 MEDICAL POTECTION SOCIETY POFESSIONAL SUPPOT AND EXPET ADVICE Membership Application Scheme of co-operation with SAMA Please complete all parts of this form in BLACK INK and BLOCK CAPITALS and return to: South African Medical Association. PO. Box 74789, Lynnwood idge, Pretoria For enquiries please telephone: (012) or fax: (012) If your application for membership of MPS is approved, it will be dated from the day following receipt of your application unless you specify a later start date in the box to the right: (DD/MM/YYYY) SECTION A PESONAL DETAILS Surname First name Title Country of practice Country of permanent residence Address for correspondence Maiden/previous name if any Date of birth (DD/MM/YYYY) Gender ID number Male Female Nationality Membership category (see rate sheet) Which hospital are you working in? (If applicable) HPCSA registration number (or other registration authority in Southern Africa) Your application may be delayed if this is not provided. Postcode (zip or postal area) address Daytime telephone Evening telephone Cell number Fax number IMPOTANT INFOMATION PLEASE EAD 1. As part of our normal process, we may approach your previous indemnity or insurance organisation for your claims history. This process will take a minimum of 15 working days. 2. Failure to disclose full and accurate details about your previous history, practice and income may invalidate your membership which means you are not entitled to any advice or assistance from MPS. 3. When completing the previous history section on pages 2 and 3 you must account for any gaps in your indemnity or insurance history during the last 10 years and also any break in clinical practice during the previous 2 years. 4. We will not assist with any matter that pre-dates your MPS membership. 5. If you are leaving a claims made insurance contract, please ensure you have notified your previous provider of any adverse incident of which you are aware, that could become a claim. You should also check with the provider whether any closing payment is required to secure run-off cover for any future claim which may arise from an incident pre-dating your MPS membership. Please note that signing the declaration on page 8 indicates acceptance of the following requirements: Members undertake to keep MPS informed of their current address and any changes in their professional circumstances. Failure to notify us of any change of address or scope of practice could result in the suspension of the benefits of membership and/or the termination of your membership. Members should understand that MPS is not an insurance company. The benefits of MPS membership are granted at the discretion of Council and are subject to the terms and conditions of the MPS Memorandum and Articles of Association, as amended from time to time. MPS office use only Processed Specialty Date form sent (DD/MM/YYYY) Start date (DD/MM/YYYY) DP Date received (DD/MM/YYYY) Joining reason Access no. Approved by Date approved (DD/MM/YYYY) Grade Status Membership no. tes MPS0412: 07/14 The Medical Protection Society Limited A company limited by guarantee. egistered in England at 33 Cavendish Square, London W1G 0PS, UK. MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association. 1

2 SECTION B PEVIOUS HISTOY PLEASE EAD THE IMPOTANT INFOMATION BELOW In this section you must include details of any matter in which you have been named or involved. Please include any pending, unresolved or closed issues, even those already reported to MPS. Failure to disclose full and accurate details about your previous history may delay your application. If necessary please continue your answers on a separate sheet.! 1. Have you had any professional indemnity/insurance before? (Please go to Q2) (Please go to Q4) 2. Please give the name of all other organisations and the dates during which you were a member or policyholder. If you were previously a member of MPS, please give your membership number and your name at the time (if it has changed). Organisation From To MPS number Name Other membership or (DD/MM/YYYY) (DD/MM/YYYY) policy number 3. Have there been any gaps in your professional indemnity during the last ten years? (If in doubt please indicate YES.) If you have answered YES please confirm the dates and the reason for any gap below. 4. Have there been any breaks in your clinical practice in the last 2 years? (If in doubt please indicate YES.) If you have answered YES please confirm the dates and the reason for any gap. Please also provide details of any continuous professional development or refresher training that has been undertaken. 5. Have you ever been refused professional indemnity/insurance, including refusal to renew or been offered limited or conditional terms or a higher/enhanced subscription/premium? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words providing dates and reasons, including copies of any correspondence. 6. Have you ever been the subject of any complaint arising out of your professional practice? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words of the events leading to the complaint(s) including dates, the extent of your involvement and also the final outcome.! If you have answered YES to any question on pages 2 and 3 please provide details as requested. Use additional pages if needed. Failure to disclose full and accurate details about your previous history may delay your application. 2

3 7. Have you ever been involved in any claim for compensation arising out of your professional practice or are you aware of any incident that might become a claim? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words of the events leading to the claim(s) declared, including dates, the extent of your involvement and also the final outcome. 8. Have you ever been the subject of a disciplinary inquiry by your employer or had practice privileges refused/withdrawn/made conditional by a private health care provider? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words to include dates, the extent of your involvement and also the final outcome. Copies of any associated correspondence must be provided. 9. Have you ever been subject to any referral, complaint, inquiry or investigation or hearing by any registration body or had conditions imposed on your practice or been suspended or erased from a medical register? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words of the events leading to the registration body inquiry/investigation, including dates, the extent of your involvement and you must provide copies of any final determination letter(s). 10. Have you ever been cautioned by the police in respect of, or convicted of, any criminal allegation (including road traffic offences)? If you have answered YES please provide a summary in your own words to include the nature of the offence, the final outcome or the current position and whether the offence was reported to any registration body. 11. Are there any other issues of which MPS might reasonably need to be aware when considering your application for membership? (If in doubt please indicate YES.) If you have answered YES please provide all relevant information below.! If you have answered YES to any question on pages 2 and 3 please provide details as requested. Use additional pages if needed. Failure to disclose full and accurate details about your previous history may delay your application. 3

4 SECTION C POFESSIONAL DETAILS (Please tick one answer only unless instructed otherwise) Your professional qualifications From which academic institution did you obtain your primary professional qualification? Please state your medical qualifications and the month/year in which they were awarded. Qualifications Date awarded (MM/YYYY) 4: Please state your annual private practice expenses (ie expenditure incurred wholly and exclusively for the purpose of your private practice as declared to the South African evenue Service). 5: On average how many hours in total do you work per week in private practice? hours 6: On average how many private patients in total do you consult per week? 1 50 patients patients patients patients patients 250+ patients 1: How are you employed? (Tick all that apply) 7: Within your private practice please indicate the average number of hours per week you spend on the following activities: Solus Academic Ships Doctor Occupational Medicine Partner Associate Salaried Locum Accident and Emergency in a private trauma/casualty unit NGO Other (please specify below) 2: What is your status? (Tick one only) State hospital only GO TO QUESTION 18 (All of your work is indemnified by the state and you only require supplementary benefits from MPS) Private practice only (All of your work is in private practice) Private & state hospital sessions (Most of your work is in private practice with some state hospital work) State hospital & private sessions (Most of your work is in a state hospital with some private practice) 3: What is your gross annual income from private practice for which you require MPS indemnity? PLEASE NOTE: Include any income paid into department funds or charity Exclude any salary from an employer who provides you with indemnity, (eg state indemnified work) Locum Work Medicolegal eporting Alcohol and Drug ehabilitation Clinical Trials epatriation of Patients 4

5 Alternative Medicine* *If you practise alternative medicine then please also indicate which of the following procedures you perform: Ayurveda Chinese Medicine and Acupuncture Chiropractic Homeopathy Naturopathy Osteopathy Phytotherapy Therapeutic Aromatherapy Therapeutic Massage Therapy Therapeutic eflexology Other (please specify below) 8: Within your private practice please indicate the average number of procedures you perform per week for each of the following: General Anaesthesia Obstetric Ultrasound 10: Do you perform any private spinal surgery (surgical procedures performed on the spine and/or meninges)? If yes, then how many procedures did you perform in the previous year and do you expect to perform in the current year? Previous year (actual) Current year (estimated) 11: Do you perform any private refractive laser surgery? If yes, then how many procedures did you perform in the previous year and do you expect to perform in the current year? Please note that each eye treated should be counted as one procedure. Previous year (actual) Current year (estimated) 12: Do you undertake any private cosmetic/aesthetic treatments or procedures? (Please tick ) GO TO QUESTION 14 If yes, please tick all cosmetic/aesthetic treatments or procedures you undertake: Botox Chemical Peels (inc. Superficial Peels) Facial Sclerotherapy Hair Transplants Microdermabrasion n-permanent Dermal Fillers Photo-ejuvenation (laser inc. IPL) Tattoo emoval Other (please specify below and include any surgical procedures performed eg Liposuction) Female Sterilisation Termination of Pregnancy Vasectomy 9: Do you perform any private deliveries? If yes, then how many private deliveries did you perform in the previous year and do you expect to perform in the current year? Previous year (actual) Current year (estimated) 13: What percentage of your gross annual income do you derive in total from Botox, nonpermanent fillers and superficial epidermal chemical facial peel procedures? 0% 51 75% 1 25% % 26 50% 14: How many private patients do you treat annually who have been referred to you by a commercial organisation? 0 patients patients 1 10 patients 100+ patients patients 5

6 15: Please indicate the number of partners, associates and locums in your private practice with the following indemnity arrangements in place: Partners Associates Locums MPS Other Indemnity Indemnity Indemnity 16: Do you employ staff other than doctors who are registered with either the HPCSA and/or AHPCSA and/or SANC and/or other registration authorities in Southern Africa? 19: Has your professional status or job changed in the last 12 months? If yes, please indicate the date of this professional change. Date: (DD/MM/YYYY) 20: Do you carry out any medical practice outside of South Africa? If yes, then please state all of the countries in which you practise. If yes, please indicate below the type and number you employ in your private practice who have the following indemnity arrangements in place. MPS Other Indemnity Indemnity Indemnity Nurse Nurse Practitioner Others (please specify below) 21: How many patients do you treat annually who have travelled from outside Africa specifically for your treatment? 0 patients patients 1 10 patients 100+ patients patients 22: Give details of any other professional activities (paid, unpaid or voluntary) for which you would look to MPS for assistance in the event of an adverse incident arising. This includes any aspect of patient care that is not evidence based or for which there is not a responsible body of medical opinion who would support your management. 17: Do you provide any private obstetric services (including ultrasound) beyond ante-natal care after 24 weeks gestation? What percentage of your working time do you spend providing these services? 1 25% 51 75% 26 50% % On average how many patients in total do you provide these services to per week? 1 25 patients patients patients patients patients 150+ patients patients 18: Are you registered as a specialist with the HPCSA or other registration authority in Southern Africa? If yes, please indicate your main specialty and if applicable your sub-specialty below. Specialty Sub-specialty 6

7 Payment details Please refer to your current subscription rate information to determine your correct subscription and indicate the amount below. If you are uncertain then please telephone SAMA on (012) Please then choose your preferred payment method from the list below and then write your cheque, or complete the direct debit instruction. eturn this entire form with any enclosures to: South African Medical Association, P.O. Box 74789, Lynnwood idge, Pretoria Method of payment I wish to pay my subscription in accordance with the following instructions: Please tick ONE of the following options as appropriate: Direct Deposit/Internet Transfer ( instalments) Bank Details: Medical Protection Society, Standard Bank, Hatfield, Pretoria. Branch code: Cheque Acc : Cheque Crossed and made payable to: Medical Protection Society ( Instalments) Annual Debit Order Please charge to my bank account on the next available month end Monthly Debit Order Please charge 10 equal instalments to my bank account collected consecutively on the last working day of the month, in months 2 11 te: Debit order facility not available in Botswana, Lesotho, Zimbabwe or Swaziland Banks. Debit order authority I hereby request and authorise MPS to draw against my account with the bank indicated below (or any bank or branch to which I may transfer my account) the amount necessary for payment of my annual membership fees to MPS. I hereby request and authorise MPS to arrange with my bank for the payment accordingly. I agree to pay all bank charges in connection with this instruction and agree that this authority will remain in force as long as I remain a member of MPS. In the event of my membership of MPS being terminated, then upon confirmation by MPS, this authority will terminate likewise. I further agree that receipt of this instruction by MPS shall be regarded as receipt thereof by my bank and understand that the payment hereto authorised will be processed by the bank electronically and that details of each payment will appear on my bank statement or on an accompanying voucher and I will advise MPS immediately it does not appear. I confirm the details provided in this authority are correct in all respects. I confirm that I will notify MPS in writing of any change in the bank details provided below at least one calendar month prior to such change. Debit order details please enclose a cancelled cheque Account type (please tick ) Current Transmission Savings Name of account holder Name of bank Branch name. Account number Signature A scheme of co-operation between MPS and SAMA The Medical Protection Society Limited. A company limited by guarantee. egistered in England at 33 Cavendish Square, London W1G 0PS, UK South African Medical Association, P.O. Box 74789, Lynnwood idge, Pretoria 0040, Castle Walk Corporate Park, Block F, ssob St, Erasmuskloof X3, Pretoria Tel: (012) Fax: (012) Incorporated association not for gain. eg. no. 1905/000136/08. 7

8 IMPOTANT! PLEASE EAD THE FOLLOWING AND SIGN BELOW Please note: By completing this form I understand that if my subscription or any other liability to MPS is in arrears for more than one month, then I shall cease to be entitled to any membership benefit from MPS from that date when such subscription or liability fell due. I also understand that after non-payment for two months MPS may terminate my membership by notice, although my liability to MPS already accrued will not be affected. I wish to apply for membership of MPS subject to the Memorandum and Articles of Association and upon payment of the appropriate subscription. I understand that membership is not granted automatically and my application is subject to approval by MPS who can at its absolute discretion refuse my application for membership. I consent to MPS seeking information regarding past and current matters from other professional protection bodies, insurance companies or employers with whom I have had professional indemnity arrangements, and to the release of that information to MPS. I consent to MPS processing information about me. (Please see data protection information below.) I consent to MPS using the address provided for communication with me. I confirm that the information I have provided is correct to the best of my knowledge and that I have read the notes and information above. I also confirm that I have completed the payment instruction on page 7. Please note: It is your responsibility to provide accurate information about your professional practice, and relevant income (which may affect the subscription you pay). Failure to notify us of any change of address or scope of practice could result in the suspension of the benefits of membership and/or the termination of your membership. Your personal information At times we will ask you to provide us with personal information including, but not limited to, when you apply for membership, change your membership, your subscription is renewed, your scope of practice changes and if you seek and we provide assistance to you. In applying for membership and by continuing as a member you agree that (i) we may hold and process your personal information, which you provide to us or which we fairly obtain from another source for the purposes of processing any application for membership, the administration and provision of membership services, providing you with benefits of membership (including, but not limited to, advice, assistance and indemnity), underwriting, risk assessment, marketing, education, research and audit during your membership and for a reasonable period after your membership terminates or an application for membership is rejected by us or withdrawn by you and (ii) we may share such information with third parties who may also hold and process the personal information for the same purposes. You also agree that (i) we may seek information relevant to any purpose for which you have agreed we may hold personal information regarding past and current matters from other professional defence organisations, insurance companies or employers with whom you have had professional indemnity arrangements or been employed and that they may release such information (ii) your personal information may be transferred to, held and processed within European Economic Area (EEA) and (iii) if you provide us with an address or telephone number it may be used by us and third parties to contact you for any of the purposes for which you have agreed to allow us or them to hold or process or process your personal information. If you are submitting additional sheets or correspondence, please tick here. In order to provide you with the best possible service we would like to inform you of other products and services offered by us that we believe may be of interest to you. If you do not wish to receive such information, either via post or , please tick here. Signature Date (DD/MM/YYYY) Please tell us why you have chosen MPS. Your comments are important to us, please tick below 1. Personal recommendation 2. Competitive subscription rates 3. MPS membership marketing representatives 4. Group arrangement 4 5. Dissatisfaction with previous organisation 6. Other (please provide details in the space provided) MPS South Africa Contact information c/o South African Medical Association P.O. Box 74789, Lynnwood idge, Pretoria 0040 South Africa Telephone (012) Facsimile (012) Website The Medical Protection Society Limited A company limited by guarantee egistered in England at 33 Cavendish Square, London W1G 0PS, UK MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association. 8