KAREENA PRIVATE HOSPITAL AND/OR KINGSWAY DAY SURGERY
APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER
________________________________________________________
NAME
DATE OF APPLICATION:
APPLICATION FORM
APPLICANT CHECKLIST
UPON COMPLETION, PLEASE FORWARD YOUR APPLICATION WITH THE FOLLOWING DOCUMENTS TO:
[NAME]
KAREENA PRIVATE HOSPITAL
86 KAREENA ROAD, CARINGBAH NSW 2229
APPLICATION FORM IS FULLY COMPLETED AND SIGNED
Yes
RAMSAY HEALTH CARE - SCOPE OF PRACTICE COMPLETED
Yes
COPY OF CURRICULUM VITAE
Yes
DOCUMENTARY EVIDENCE OF QUALIFICATIONS
Yes
COPY OF EPA RADIATION LICENCE
Yes
N/A
COPY OF LASER CERTIFICATE
Yes
N/A
AHPRA REGISTRATION CERTIFICATE
Yes
PROFESSIONAL INDEMNITY INSURANCE CERTIFICATE & POLICY SCHEDULE
Yes
WORKING WITH CHILDREN CLEARANCE
Yes
N/A
IN PROGRESS
DATE COMPLETED
HOSPITAL USE ONLY
1.
APPLICATION SIGNED
2.
ALL MANDATORY DOCUMENTATION RECEIVED
3.
REFERENCES RECEIVED
4.
DISTRIBUTED TO OTHER RHC FACILITIES (WHERE APPLICABLE)
5.
SIGNED OFF BY CEO
6.
APPROVED BY HOSPITAL CREDENTIALING COMMITTEE
7.
APPROVED BY HOSPITAL MEDICAL ADVISORY COMMITTEE
8.
RATIFIED BY RHC CENTRAL CREDENTIALING COMMITTEE
GROUP CLINICAL GOVERNANCE UNIT
UPDATED: AUGUST 2013
VERSION: V8.7
PAGE 1 of 10
KAREENA PRIVATE HOSPITAL AND/OR KINGSWAY DAY SURGERY
APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER
1.
NAME
2.
SPECIALTY
3.
APPOINTMENT REQUEST(S)
Primary Facility:
NEW SOUTH WALES
Albury Wodonga Private Hosp.
Kareena Private Hospital
Port Macquarie Priv. Hosp.
Armidale Private Hospital
Kingsway Day Surgery
Southern Highlands Priv. Hosp.
Baringa Private Hospital
Southern Highlands Cancer Cntr.
Berkeley Vale Private Hospital
Lake Macquarie Private Lake
LakeMacquarie Priv. Hosp.
Lawrence Hargrave Priv. Hosp.
St George Private Hospital
Castlecrag Private Hospital
Mt Wilga Private Hospital
Strathfield Private Hospital
Coffs Harbour Day Surgical Cntr.
North Shore Private Hospital
Tamara Private Hospital
Coolenberg Day Surgery
Northside Clinic
Warners Bay Private Hospital
Dudley Private Hospital
Northside Cremorne Clinic
Westmead Private Hospital
Figtree Private Hospital
Northside Macarthur Clinic
Hunters Hill Private Hospital
Northside West Clinic
Western Sydney Oncology &
Infusion Centre
Hastings Day Surgery
Nowra Private Hospital
Caboolture Private Hospital
QUEENSLAND
John Flynn Priv. Hospital
Pindara Day Procedure Cntr.
Cairns Private Hospital
Nambour Selangor Priv. Hosp.
Short Street Day Surgery
Cairns Day Surgery
New Farm Clinic
St Andrews Ipswich Priv. Hosp.
Caloundra Private Clinic
Noosa Hospital
Sunshine Coast Uni. Priv. Hosp.
Greenslopes Private Hospital
North West Private Hosp.
The Cairns Clinic
Hillcrest Private Hospital
Pindara Private Hospital
SOUTH AUSTRALIA
Adelaide Clinic
Fullarton Private Hospital
Kahlyn Day Centre
VICTORIA
Albert Road Clinic
Masada Private Hospital
The Avenue Hospital
Beleura Private Hospital
Mildura Base Hospital
Wangaratta Private Hospital
Donvale Rehabilitation Hosp.
Mitcham Private Hospital
Warringal Private Hospital
Frances Perry House
Murray Valley Priv. Hosp.
Waverley Private Hospital
Glenferrie Private Hospital
Peninsula Private Hospital
Linacre Private Hospital
Shepparton Private Hospital
WESTERN AUSTRALIA
Attadale Private Hospital
Hollywood Private Hospital
Glengarry Private Hospital
Joondalup Health Campus
4.
Peel Health Campus
CATEGORY, SCOPE OF PRACTICE AND SPECIALTY
GROUP CLINICAL GOVERNANCE UNIT
UPDATED: SEPTEMBER 2014
VERSION: V8.7
PAGE 2 of 10
KAREENA PRIVATE HOSPITAL AND/OR KINGSWAY DAY SURGERY
APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER
I apply to Ramsay Health Care for Appointment as an Accredited Practitioner and seek appointment for
the Category and Scope of Practice indicated. To support my application I submit all relevant information
as detailed in the summary Check List.
CLINICAL PRACTICE SOUGHT IN THE FOLLOWING CATEGORIES
Career Medical Officer
Registrar
Consultant Emeritus
Specialist Practitioner
Dentist
Staff Specialist
Fellow Practitioner
Surgical Assistant
General Practitioner
CREDENTIALED TO:
(PLEASE TICK)
Admit
Diagnostic / Treat
Consult
Assist
SPECIALTY IN WHICH ACCREDITATION IS APPLIED FOR:
DOES YOUR SCOPE OF PRACTICE REQUIRE
THE USE OF :
FLUOROSCOPY AND/OR ANGIOGRAPHY
EQUIPMENT :
(if Yes, please provide:)
Yes
No
EPA Radiation Licence Expiry Date
Yes
No
LASER EQUIPMENT :
Laser Certificate Expiry Date
If yes to any of the above, please attached copy of EPA Radiation Licence and/or Laser
Certification of Accreditation.
SPECIALTY SCOPE OF CLINICAL PRACTICE
Please complete Scope of Practice (Appendix 1 - V1) to complete your Specialty (not required for
Surgical Assistants
5.
APPOINTMENT PERIOD (TO BE COMPLETED BY FACILITY)
Temporary
5 Years
GROUP CLINICAL GOVERNANCE UNIT
Other Term
UPDATED: SEPTEMBER 2014
/
/ 20
to
VERSION: V8.7
/
/ 20
PAGE 3 of 10
KAREENA PRIVATE HOSPITAL AND/OR KINGSWAY DAY SURGERY
APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER
6.
PERSONAL DETAILS
NAME
TITLE:
SURNAME
(Dr, Mr, Prof, A/Prof)
ANY FORMER NAME
GIVEN NAME
INCLUDING MAIDEN NAME
PRESCRIBER NO
PROVIDER NO.
DATE OF BIRTH
PROVIDER NO.
PERSONAL CONTACT IN
CASE OF EMERGENCY:
PARTNER’S FULL NAME
EMERGENCY CONTACT
PERSON’S MOBILE:
PARTNER’S TITLE:
(DR, MRS, MR)
(FOR INVITATION PURPOSES)
PERSONAL ADDRESS
RESIDENTIAL ADDRESS
SUBURB
POSTCODE
TELEPHONE
PAGER NO.
FACSIMILE
MOBILE NO.
EMAIL
PRACTICE ADDRESS
PRACTICE ADDRESS
SUBURB
POSTCODE
POSTAL ADDRESS
POSTCODE
TELEPHONE
FACSIMILE
EMAIL
Preferred Mailing
Address:
Personal
Practice
Other (provide details)
OTHER
GROUP CLINICAL GOVERNANCE UNIT
UPDATED: SEPTEMBER 2014
VERSION: V8.7
PAGE 4 of 10
KAREENA PRIVATE HOSPITAL AND/OR KINGSWAY DAY SURGERY
APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER
7.
QUALIFICATIONS
Please attach Curriculum Vitae and Qualification Documents
DEGREE / FELLOWSHIP
8.
YEAR
APPOINTMENTS
SINCE
CURRENT APPOINTMENTS
FACILITY
9.
CONFERRING BODY
PAST APPOINTMENTS
FACILITY
APPOINTMENTS
FROM / TO
10. REFERENCES (NEW APPLICANTS ONLY)
Please provide contact details for three professional referees who can attest that your recent practice
consistent with the criteria contained within the RHC Facility Rules and hospital Code of Conduct. Please
refer to Rules 48 and 49.3. The referees provided should be familiar with your current professional
capabilities.
Please note that your referees will be contacted and asked to provide a reference.
GROUP CLINICAL GOVERNANCE UNIT
UPDATED: SEPTEMBER 2014
VERSION: V8.7
PAGE 5 of 10
KAREENA PRIVATE HOSPITAL AND/OR KINGSWAY DAY SURGERY
APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER
1ST REFEREE
NAME
ADDRESS
TELEPHONE:
FAX:
EMAIL
2ND REFEREE
NAME
ADDRESS
TELEPHONE:
FAX:
EMAIL
3RD REFEREE
NAME
ADDRESS
TELEPHONE:
FAX:
EMAIL
11. AHPRA REGISTRATION
Please attach your current Registration Certificate
Please refer to RHC Facility Rules 118 and 119 and sub-clauses 119.1 to 119.9 regarding APHRA registration and
continuous disclosure requirements.
EXPIRY DATE
REGISTRATION NO
DO YOU HAVE ANY :
(PROVIDE DETAILS)
DO YOU HAVE ANY:
(PROVIDE DETAILS)
Endorsements
Notations
Conditions
Undertakings
Reprimands
SHOULD AHPRA IMPOSE ANY CONDITIONS AND/OR RESTRICTIONS ON MY MEDICAL REGISTRATION, IN THE
FUTURE, I CONFIRM THAT I WILL IMMEDIATELY NOTIFY THE HOSPITAL’S CEO OF THE NATURE AND EXTENT OF
SUCH CONDITIONS AND/OR RESTRICTIONS?
GROUP CLINICAL GOVERNANCE UNIT
UPDATED: SEPTEMBER 2014
VERSION: V8.7
NO
YES
PAGE 6 of 10
KAREENA PRIVATE HOSPITAL AND/OR KINGSWAY DAY SURGERY
APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER
12.
PROFESSIONAL INDEMNITY INSURANCE
Please attach your current Professional Indemnity Insurance Certificate & Schedule
Please refer to RHC Facility Rules 35.2, 49.2, 59.2 and clauses 218.13 and 218.4 of Schedule 1 for professional
indemnity insurance requirements for Accredited Practitioners (see definitions - 6.5 and 6.6).
Accredited Practitioners must hold professional indemnity insurance cover issued by an Australian insurer. Ramsay
Health Care policy requires that all Accredited Practitioners hold a minimum level of cover of $20 million for each
claim and in the aggregate.
Please note it is a requirement to furnish a copy annually to the Hospital CEO as documentary evidence of the level
of cover and also to immediately advise any material changes to the level of cover or conditions of the policy.
Please contact the Hospital CEO if you have any queries.
INDEMNITY INSURANCE
POLICY NO
INSURANCE
COMPANY
NO
YES
YES
NO
DO YOU HAVE CURRENT PROFESSIONAL INDEMNITY INSURANCE COVER OF $20 MILLION FOR EACH CLAIM AND IN
THE AGGREGATE.?
DO YOU HAVE ANY CONDITIONS IMPOSED BY YOUR INDEMNITY INSURANCE PROVIDER THAT YOU ARE REQUIRED
TO COMPLY WITH IN ORDER TO MAINTAIN COVERAGE?
(IF SO, PLEASE PROVIDE A COPY OF THE RELEVANT SECTION OF YOUR INSURANCE POLICY)
I CONSENT TO RAMSAY HEALTH CARE CONTACTING MY INDEMNITY INSURANCE PROVIDER DIRECTLY, SHOULD IT
DESIRE FOR ANY REASON, TO OBTAIN A FULL COPY OF MY INDEMNITY INSURANCE POLICY? (IF YES, PLEASE
PROVIDE SIGNED AUTHORITY)
SHOULD MY INDEMNITY INSURANCE PROVIDER IMPOSE ANY CONDITIONS AND/OR RESTRICIONS ON MY
INDEMNITY INSURANCE POLICY, IN THE FUTURE, I CONFIRM THAT I WILL IMMEDIATELY NOTIFY THE HOSPITAL
CEO OF THE NATURE AND EXTENT OF SUCH CONDITIONS AND/OR RESTRICTIONS?
13. DISCLOSURE
A
Have you ever had any restrictions / conditions placed on your Medical
Registration?
(If you answered yes to the above, please provide details including details of the restrictions / conditions and period during which the
restrictions apply / applied):
B
Have you previously been refused credentialing or renewal of credentialing at
another health care facility?
YES
NO
(If you answered yes to the above, please provide name of the facility & rationale for refusal. Please note: A senior executive of the hospital
may contact the facility)
GROUP CLINICAL GOVERNANCE UNIT
UPDATED: SEPTEMBER 2014
VERSION: V8.7
PAGE 7 of 10
KAREENA PRIVATE HOSPITAL AND/OR KINGSWAY DAY SURGERY
APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER
13.
C
DISCLOSURE (CONT.)
Has your Scope of Practice been restricted, suspended, conditions imposed, or
written recommendations made by any other health care facility?
NO
YES
NO
YES
NO
YES
NO
(If you answered yes to the above, please provide name of the facility & rationale for refusal. Please note, a
senior executive of the hospital may contact the facility)
Are you currently under investigation or have there ever been any serious adverse
findings made against you which would be relevant to your appointment (for example:
D
breach of insurance / medical laws, professional misconduct, sexual assaults or assault) by: The Health
Insurance Commission, a Medical Board, a Health Care Complaints Commission/body, a Coroner, a Court or
any other professional disciplinary or similar body?
(If you answered yes to the above, please provide details)
E
Do you have any illness or disability which may adversely affect your current fitness
to practice? (If you answered yes to the above, please provide details)
F
Criminal Record Check – have you been convicted of, or pleaded guilty to, a criminal
offence including a serious sex or violence offence, an offence involving dishonesty
or drugs or committed, or charged with, a criminal indictable offence (other than a
spent conviction)? (If you answered yes to the above, please provide details)
G
YES
Working with Children – complete if applicable
A Working with Children Check is required of applicants who will be undertaking direct and unsupervised
contact with children in the course of their work.
WWCC
Clearance No.
YES
NO
YES
NO
Are you likely to be undertaking child related work meeting the definition above?
If you answered yes to the above question, do you consent to make a prohibited
Employment Declaration and a Background Check, as prescribed by the relevant law?
Please attach your current Working With Children Clearance Certificate
GROUP CLINICAL GOVERNANCE UNIT
UPDATED: SEPTEMBER 2014
VERSION: V8.7
PAGE 8 of 10
KAREENA PRIVATE HOSPITAL AND/OR KINGSWAY DAY SURGERY
APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER
14. NOMINATED ALTERNATE ACCREDITED PRACTITIONER IN THE EVENT OF AN
EMERGENCY (NOTE: NOMINEE(S) MUST BE ACCREDITED AT THE RHC FACILITY, WHERE APPLICANT IS
SEEKING PRIVILEGES, WITH EQUIVALENT SCOPE OF PRACTICE) (NOT APPLICABLE FOR SURGICAL ASSISTANTS)
In the event that I am unable to be contacted for a clinical emergency, the person nominated below is a
Ramsay Health Care Accredited Practitioner who has agreed to deputise for me:
NOMINEE(S)
RHC FACILITY
CONTACT NUMBER:
15. CONFIRMATION
I confirm that the information contained in this document is true and accurate and is not misleading or deceiving or
likely to mislead or deceive.
I understand that if I have provided misleading or deceptive information or information which is likely to mislead or
deceive that the Board of Ramsay Health Care Pty Limited may (in its absolute discretion) consider that I do not have
“current fitness” under the RHC Facility Rules.
I agree that I will notify the CEO of Kareena Private Hosptial of any material changes to the information provided by
me in connection with this application as soon as possible after the change.
I understand that my Appointment as an Accredited Practitioner, if granted, will be reviewed in [Insert Number]
years or earlier if considered necessary.
I acknowledge that I have been provided with and read a copy of the RHC Facility Rules. If appointed, I agree to
abide by the RHC Facility Rules Kareena Private Hospital policies.
Applicant’s Name:
Signature:
Date:
Witness Name:
Witness Signature:
GROUP CLINICAL GOVERNANCE UNIT
Date:
UPDATED: SEPTEMBER 2014
VERSION: V8.7
PAGE 9 of 10
KAREENA PRIVATE HOSPITAL AND/OR KINGSWAY DAY SURGERY
APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER
FOR HOSPITAL USE ONLY
New Appointment
Temporary
Expiry Date:
Approved by Chief Executive Officer
Name
Signature
Date
Recommended by the Hospital’s Credentialing Committee
Delegate’s Name
Signature
Date
Recommended by Medical Advisory Committee
Delegate’s Name
Signature
Date
Recommended by RHC Central Credentialing Committee
Approved by Ramsay Health Care Board of Directors as evidenced by the letter sent on
behalf of the Board confirming the appointment.
GROUP CLINICAL GOVERNANCE UNIT
UPDATED: SEPTEMBER 2014
Date
VERSION: V8.7
PAGE 10 of 10