Practice Incentives Individual general practitioner or nurse

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Practice Incentives
Individual general practitioner or
nurse practitioner details
Purpose of this form
For more information
Complete this form to notify the Australian Government Department
of Human Services (Human Services) of additional general
practitioners or nurse practitioners who join the practice after the
practice has registered for the Practice Incentives Program (PIP) and/
or the Practice Nurse Incentive Program (PNIP). This applies for all
PIP and PNIP practices. Individual general practitioners who meet the
eligibility criteria for the PIP Procedural General Practitioner Payment
and choose this practice to receive those payments, are to complete
the Procedural General Practitioner details section of this form.
For more information about incentive programs for practices, go to
our website humanservices.gov.au/healthprofessionals >
Incentives and Allowances or email
[email protected] or [email protected]
www.
If you need assistance completing this form, call the incentives
enquiry line on 1800 222 032 Monday to Friday, between 8.30 am
and 5.00 pm, Australian Central Standard Time.
Note: Call charges apply from mobile phones.
Filling in this form
Important information
• Please use black or blue pen
• Print in BLOCK LETTERS
• Mark boxes like this
with a ✓ or 7
Health Professionals Online Services (HPOS) provides secure and
convenient online services for health professionals and
administrators.
Using your Medicare Public Key Infrastructure (PKI) Individual
certificate, you can update your practice details through HPOS.
Changes you make through HPOS are effective immediately. To
register for a Medicare PKI certificate and to find out more about
HPOS, go to humanservices.gov.au/hpos
• Where you see a box like this
Go to 5 skip to the question
number shown. You do not need to answer the questions in
between.
While you are waiting for your Medicare PKI certificate to be issued,
you may complete this form and send it to us for manual processing.
Please note that delays may occur.
Check that you have answered all the questions you need to answer
and that you have signed and dated this form.
Send the completed form to:
Department of Human Services
Incentive Programs
GPO Box 2572
ADELAIDE SA 5001
or
Fax: 1300 587 696
Returning your form
www.
A separate form for each additional general practitioner or nurse
practitioner is required.
Definition of general practitioners and nurse
practitioners
For the purposes of these incentives, general
practitioners include:
Practice details
• general practitioners
• non-specialist medical practitioners, known as other medical
practitioners, who provide non-referred services and are not
general practitioners
• fellows of the Royal Australian College of General Practitioners
(RACGP)
• fellows of the Australian College of Rural and Remote Medicine
(ACRRM)
• vocationally registered general practitioners, and
• medical practitioners undertaking approved training.
1 The practice participates in the:
Tick ALL that apply
Practice Incentives Program
Practice Nurse Incentive Program
2 Practice ID
3 Australian Business Number (ABN)
For the purposes of these incentives, a nurse practitioner
is a person who is:
• endorsed as a nurse practitioner by the Nursing and Midwifery
Board of Australia.
Registration requirements for nurse practitioners can be found at the
Nursing and Midwifery Board of Australia website
nursingmidwiferyboard.gov.au
www.
Participating nurse practitioners who provide Medicare services
are not eligible to claim those hours under the PNIP.
IP003.1406 (formerly 2746)
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4
9
The practice address is the address from which you render
services.
Full address – main practice location
Practice name
Do you have current professional indemnity cover?
No
The practice is not eligible for the PIP and/or the PNIP.
Yes
Give details below
Building name
Professional indemnity insurance company name
Unit
Suite
Street number
Shop
Floor number
Expiry date
/
/
Start date at the practice
Suburb
/
State
/
End date at the practice (if applicable)
Postcode
/
5 Practice phone number
/
11 If you have an Individual Medicare PKI certificate, you should
)
provide the Registration Authority (RA) number below:
Fax number
(
)
The RA number is located on the tag attached to the Medicare
PKI Universal Serial Bus (USB) Key or on the card sent with the
USB card reader.
The RA number will be used to allow access to the PIP and the
PNIP Online.
Email
@
Additional practice branch details (if applicable)
General practitioner or nurse practitioner details
12 Provider number and address for each additional practice
Applicants are to complete all questions in the general practitioner
or nurse practitioner details section of this form. Procedural
General Practitioners must complete questions 13 and 14.
branch (if applicable).
Additional practice branch 1
Provider number
6 Full name of general practitioner or nurse practitioner
Full practice address
Building name
7 Do you consent to the use of your Human Services and
Department of Veterans’ Affairs service data when calculating
the practice’s incentive payment(s)?
No
If you do not consent, Human Services will exclude
your data when calculating the practice’s payment(s).
This will affect the level of payment to the practice.
Yes
Unit
Suite
Street number
8 Are you a current provider at the practice?
No
Policy number
10 Provider number for the main practice location
Street name
(
It is an entry requirement of both the PIP and the PNIP that all
current practice general practitioners and nurse practitioners
have current professional indemnity cover.
Shop
Street name
This will affect the level of payment to the practice
for the PNIP.
Suburb
Yes
State
Postcode
Start date at the practice
/
/
End date at the practice (if applicable)
/
IP003.1406 (formerly 2746)
2 of 4
/
Floor number
14 Tick ONE box that best applies to you:
Additional practice branch 2
Provider number
Tier 1
Full practice address
Building name
Tier 2
Unit
Suite
Street number
Shop
Floor number
Tier 3
Street name
Suburb
Tier 4
State
Postcode
Start date at the practice
/
Contact us on 1800 222 032 if you are a single general
practitioner practice and may not meet the requirements of
Tier 4, but expect to meet the obstetric needs of your
community.
General practitioners are individually assessed. Practices with
more than 1 Procedural GP cannot count the combined number of
deliveries to qualify for Tier 4. For more information on reference
periods and the point-in-time date for the 6 monthly payments,
refer to the Practice Incentives Program Procedural General
Practitioner Payment Guidelines.
/
End date at the practice (if applicable)
/
/
If you have more than 2 additional practice branches,
attach a separate sheet with details.
Procedural General Practitioner details
Human Services must be advised in writing by no later than
7 days prior to the relevant point-in-time date if the required
number of procedural services have not been provided in the
6 month reference period.
13 Are you a Procedural General Practitioner (GP)?
A Procedural GP provides non-referred services, normally in a
hospital theatre, maternity care setting or appropriately
equipped facility, which in urban areas are typically the province
of a specific referral-based specialty. These services are
provided in obstetrics, surgery and anaesthetics. The PIP
Procedural GP Payment can only be made to 1 practice per 6
month reference period per Procedural GP. If you choose this
practice to receive the Procedural GP Payment, indicate the
provider number to be used below that is associated with this
practice.
No
Go to 15
Yes
Provider number
Privacy notice
15 Your personal information is protected by law, including by the
Privacy Act 1988.
Personal information and other information about a practice that
is participating in the Practice Incentives Program (PIP) and/or
the Practice Nurse Incentive Program (PNIP), or is applying to
participate in the PIP and/or PNIP, is collected by the Australian
Government Department of Human Services for the assessment
and administration of PIP and/or PNIP payments and services.
This information will be disclosed to the Department of Health
and the Department of Veterans’ Affairs to enable that
department to administer aspects of PIP and/or PNIP, for
statistical and research purposes and to inform policy
development.
The Department of Human Services may use or disclose your
personal information for other purposes where that is required
or authorised by law, or if you agree.
You can get more information about the way in which the
Department of Human Services will manage your personal
information, including our privacy policy, at
humanservices.gov.au/privacy or by requesting a copy from
the Department of Human Services.
To be eligible for the PIP Procedural GP Payment, the practice
must be located in Rural, Remote and Metropolitan Areas
(RRMA) 3–7 and meet the requirements as set out in the
Practice Incentives Program Procedural General
Practitioner Payment Guidelines, available from
humanservices.gov.au/healthprofessionals > Incentives
and Allowances > Practice Incentives Program
www.
www.
IP003.1406 (formerly 2746)
I provide at least 1 procedural service in the
6 month reference period. Refer to the
Practice Incentives Program Procedural
General Practitioner Payment Guidelines for
the definition of a procedural service.
I meet the Tier 1 requirements and provide
procedural services after hours (as defined in
the Practice Incentives Program Procedural
General Practitioner Payment Guidelines)
on a regular or rostered basis throughout the 6
month reference period.
I meet the Tier 2 requirements and provide 25
or more eligible surgical and/or anaesthetic
and/or obstetric services in the 6 month
reference period.
I meet the Tier 2 requirements and deliver
10 or more babies in the 6 month reference
period.
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Individual general practitioner and nurse practitioner
declaration
16 I consent to:
• the Australian Government Department of Human Services
accessing information, including personal information, held
by itself or the Department of Veterans’ Affairs about
medical services provided by me for the purposes of
calculating payments for the practice.
I understand that:
• giving false or misleading information is a serious offence.
• the Australian Government Department of Human Services
can make relevant enquiries and may access information
for the purpose of calculating payments.
• the Australian Government Department of Human Services
may provide reports regarding information and services
provided by me to the authorised contact person(s).
• I must advise the Australian Government Department of
Human Services in writing of any changes to my
arrangements by no later than 7 days prior to the relevant
point-in-time date.
• if this is not done, incentive payments may be reduced or
recovered and the practice’s eligibility for incentive
programs may be affected.
I declare that:
• the information I have provided in this form is complete and
correct.
• I have not claimed these procedural services at another
practice (if applicable).
General practitioner’s full name
General practitioner’s signature
Date
/
/
or
Nurse practitioner’s full name
Nurse practitioner’s signature
Office use only
PIP processing completed
Operator ID
Date
/
/
Date processed
Reset form
Print form
/
/
Date forwarded to PNIP
/
PNIP processing completed
Operator ID
Date processed
/
IP003.1406 (formerly 2746)
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/
/
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