Annexure A1: Application for Accreditation Medical Practitioner or Dentist (Including Surgical Assistants) Application for Accreditation Application for Accreditation as a Medical Practitioner including Surgical Assistants or Dentist Please submit completed application form to the General Manager / Director of Nursing at: New Appointment Reappointment For Reappointment: If this is an application for reappointment and there are no changes to the information required in this application you will only be required to tick the box, sign and complete your contact details on this application. This is an application for my reappointment and there are no changes to the information required in the Application for Accreditation since I last applied. Signature of Medical Practitioner Date Surname of Applicant: First Names in full: Date of birth (optional): Accreditation category: (Please refer to page 3 for the list of category) Name of Partner/Spouse: (optional - for hospital invitation list only) Please tick preferred mailing address: Residential Address with postcode: Home Phone: Home Fax: Professional address with postcode (include PO Box): Primary Consulting Room Rooms Telephone: Pager Telephone: Mobile Number: Email Professional address (other consulting rooms): Rooms Fax: Pager : Provider : Undergraduate qualifications, university and year of graduation: Postgraduate qualifications, degrees, diplomas: (Attach CV if insufficient space) te: Certified copies of original qualifications should be obtained, if possible Hospital Appointments within last ten years: Dates: Hospital: Appointment: Document Number: EHC-FORM-EXEC-07 Page 40 of 67
Itemise Postgraduate Educational Activity in the past three years: Nature of current practice, place of work and special professional interests: Publications (Please attach list or CV): Accreditation sought in the following category(s): Specialist Practitioner Staff Specialist Dental Specialist Consultant Specialist/General Practitioner ( admitting rights) General Practitioner Dentist Consultant Emeritus ( admitting rights) Surgical Assistant ( admitting rights) House Medical Officer (Resident, Registrar, Career Medical Officer) Registered speciality/sub-specialties: Surgical Assistant applicants only: Name of accredited practitioner at each applicable hospital who will provide a reference for you. Accreditation (Please tick): Permanent Temporary from to Document Number: EHC-FORM-EXEC-07 Page 41 of 67
Clinical privileges are sought in the field(s) of: (NOT APPLICABLE to surgical assistants) [ ] ANAESTHESIA Cardiac Pain [ ] CARDIOLOGY TOE Diagnostic Angiography Interventional Procedures Angioplasty EPS [ ] CARDIOTHORACIC SURGERY [ ] INFECTIOUS DISEASES [ ] INTENSIVE CARE [ ] NEONATOLOGY [ ] NEUROSURGERY [ ] NUCLEAR MEDICINE [ ] OBSTETRICS & GYNAECOLOGY Gynaecology General Obstetrics Gynaecology Oncology Advanced Endoscopic Surgery [ ] PHYSICIANS/INTERNAL MEDICINE General Medicine Endocrinology Geriatrics Neurology Renal Medicine Respiratory Physicians Rheumatology [ ] PLASTIC & RECONSTRUCTIVE SURGERY Hand Surgery Facio-Maxillary Surgery Plastic, Reconstructive & Aesthetic Surgery Head & Neck [ ] PSCHIATRY Sub-Specialty Specify: [ ] COLORECTAL SURGERY Laparoscopic Surgery [ ] COSMETIC SURGERY [ ] OCCUPATIONAL MEDICINE [ ] RADIOLOGY [ ] REHABILITATION MEDICINE [ ] DENTAL [ ] DENTAL SPECIALIST Specify: [ ] ONCOLOGY Medical Oncology Radiation Oncology [ ] OPHTHALMOLOGY [ ] UROLOGY [ ] VASCULAR [ ] DERMATOLOGY [ ] EMERGENCY MEDICINE [ ] ORAL & MAXILLOFACIAL SURGERY Facio-Maxillary Surgery [ ] ENT SURGERY Endoscopic Head and Neck [ ] GASTROENTEROLOGY Endoscopy ERCP [ ] ORTHOPAEDICS [ ] PAEDIATRIC MEDICINE [ ] PAEDIATRIC SURGERY [ ] GENERAL SURGERY Endoscopy Laparoscopic Surgery [ ] NEONATAL [ ] PALLATIVE CARE [ ] PATHOLOGY Document Number: EHC-FORM-EXEC-07 Page 42 of 67
Other privileges sought: (t applicable to surgical assistants) Field Surgical Admitting Medical Admitting Consulting Other (specify) For each speciality in which you are seeking privileges, please provide names, addresses and telephone numbers of at least two peer referees in Australia who can attest to your recent practice and who are not related to you nor financially linked with or financially dependent on you. (t applicable to surgical assistants). NB: Two (2) written references must be provided, and may be in the form of an email response to a formal reference request by an Evolution Healthcare Hospital. Specialty 1: Name of Referee 1: Name of Referee 2: Contact Details: Specialty 2: Contact Details: Name of Referee 1: Name of Referee 2: Contact details: Contact details: Please record your current registration number with the relevant State Medical or Dental Board (as appropriate) and provide photocopy: State(s): Number(s): Are there any conditions attached to this registration? If, provide details of conditions: Certified copy of your National Criminal History Record Check attached The following WWCC information must be supplied/reviewed/retained: Full name (VMO to provide); WWCC Number (VMO to provide); Date and outcome of WWCC validation (employer to complete and retain) WWCC expiry date (employer to complete and retain) (why?) (why?) NB: The individual can go to http://www.kidsguardian.nsw.gov.au/working-withchildren/working-with-children-check for more information on how to apply for a WWCC. Please state the name of your Medical Defence Organisation or your Professional Indemnity Insurance Provider and provide photocopy: Name: Membership Number: Category of membership: (insert specialty) e.g. full surgeon Billing less than $(insert amount) (insert specialty) Does your membership fully cover the types of privileges you have applied for? Appointment at other hospitals or day procedures centres: Document Number: EHC-FORM-EXEC-07 Page 43 of 67
Membership of colleges and/or other relevant Associations: 1. 2. 3. 4. Any additional information: Are you currently, or have you ever been the subject of any clinical negligence proceedings, claims or suits whatsoever? Have your clinical privileges and/or appointment 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? Has the Medical Board of Australia ever imposed conditions on your registration? If, provide details of the condition(s) imposed. Have you ever been convicted of a criminal charge or offence in Australia of overseas (not including any spent convictions)? NB: A criminal charge or convictions does not automatically preclude engagement. Each case must be considered on its merits and in accordance with the requirements of the Employment Screening Policy. If, give dates and particulars: Please nominate a medical practitioner accredited at the hospital in your specialty available for contact by the Hospital in case of an emergency if you are unavailable: Name: Specialty: Contact Numbers: Specialist Directory: (t applicable to surgical assistants) I authorise the Hospital to include my details in the Hospitals Specialist Directory Authority: I hereby apply for accreditation at: Shellharbour Private Hospital South Coast Private Canberra Private Hospital Waratah Private Hospital with clinical privileges I have also specified. In making this application I acknowledge and agree: I have received a copy of the Evolution Healthcare Hospital Bylaws. I will abide by the Bylaws, as amended from time to time. The Hospital executives, its officers and the medical advisory committee may seek information about my past experience, clinical performance and current fitness. Signature: Date: te: Evidence of Medical Defence Organisation and registration with the relevant state(s) Medical Board(s) must accompany this application. Document Number: EHC-FORM-EXEC-07 Approved By: EHC Board Dated: October 2015 Page 44 of 67 Revision: 6 Replaces Revision: 5