Government of Western Australia
MEDICAL PRACTITIONER RE-APPLICATION
AND RE-CREDENTIALLING VERIFICATION
FORM
Department of Health
(INSERT HOSPITAL/HEALTH SERVICE
NAME) Area Health Service
The scope of practice cannot be defined for a period of more than five years
FORM 4.4
Section 1
SURNAME
FIRST NAMES
HOME ADDRESS
SUBURB
POST CODE
TELEPHONE No
MAIN PRACTICE ADDRESS
SUBURB
POST CODE
TELEPHONE No
MOBILE/ AFTER HOURS
CONTACT No
1.
EMAIL ADDRESS:
FAX No
PAGER No
DATE OF BIRTH
2.
Current Position
FTE
Previous Credentialling and Scope of Practice Granted
Section 2
Previous Credentialling & Scope of Practice Granted - locations
Insert applicable names of Hospitals/ Health services
Tick where applicable
Date Approved
Section 3
Extension of Scope of Practice: Identify any additional procedures or clinical activities you are now
performing since you were last Credentialled.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Section 4
Give details if new scope of practice is being sought:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
1
Section 5
Education, training, experience and outcome information if new scope of clinical practice is being
sought:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Section 6
Provide evidence of current Medical Board Registration, including any conditions of registration:
MEDICAL BOARD NUMBER:________________________
Section 7
Give details of education, training and experience gained since the last review, including medical
college or specialist society endorsement or accreditation (including allocated list of CME activity and
points)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Section 8
Summary of clinical activity since last review or at least for the past twelve months, which may include
volume and outcomes – eg log book if maintained
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Section 9
Please give details of Quality Assurance / Improvement activities:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
2
Please confirm (tick) you have the following
Criminal Records Screening
(copy required)
clearances if applicable:
Yes
Number and expiry date…………………..
Screening is a mandatory requirement for
No
employment
Mandatory Reporting of Child
Working with Children
Aged Care Certificate
(if applicable - copy required)
(if applicable - copy required)
Sexual Abuse Training (copy of
Yes
Number
and
expiry
Yes
Number and expiry
evidence required) Yes
date………………….. No
date………………….. No
No
Section 10
Performance Management Reports
Section 11
Give details of future aspirations
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Section 12
Applicants are required to answer the following:
1. In the last five years, have you been denied scope of clinical practice
for which you have applied?
Yes
No
Yes
No
Yes
No
Yes
No
If yes please give particulars:
2. In the last five years, has your scope of clinical practice been
reduced, suspended or revoked, or under review by hospital for any
reason?
If yes please give particulars:
3. (a) In the last five years, have you made a notification to your Medical
Defence Association or Risk Cover concerning any incurred claims or
damages or other compensation for alleged negligence committed in
the course of your medical practice?
If yes please give particulars:
3 (b) In the last five years, have you had a judgement against you
regarding incidents reported to the Medical Board, or a Coronial
Inquiry?
If yes please give particulars:
3
3 (c) In the last five years, have you made an out of court settlement (or
has an out of court settlement been made on your behalf) regarding
your medical practice in any State or Territory of Australia or any other
country?
Yes
No
If yes please give particulars:
Section 13
Additional information in support of application (continue on a separate sheet if necessary)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Section 14
Please include the following documents with this application:
1.
2.
3.
Current Job Description
Current Curriculum Vitae
Copy of current professional indemnity insurance (type and scope), if applicable
Section 15
Declaration

I declare that I am the person named in this application and that to the best of my knowledge the
statements herein contained are true in substance and in fact.
Consent

I consent to Workforce officers to obtain, retain and share credentialling information within WA Health.
Signed:
_________________________________________
Print Name:
_________________________________________ Date:
4
/
/