Application for Accreditation

Healthe Care Australia Pty Ltd Hospital By-Laws Jun-10

Application for Accreditation

South Eastern & The Valley Private Hospitals

Application for Accreditation as a Medical Practitioner including Surgical Assistants or Dentist

Please submit completed application form to Lisa Keppel, Executive Assistant, PO Box 258,

Noble Park, 3174 or email southeastern.executive@healthecare.com.au

or fax 9562 3486

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 (Page 1), Scope of Practice and Consent forms 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:

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:

Prescriber Number:

Rooms Fax:

Pager No:

Preferred After Hours Number:

Provider Number:

Email Address:

Page 1


Professional address (other consulting rooms):

Undergraduate qualifications, university and year of graduation:

Postgraduate qualifications, degrees, diplomas: (Attach CV)

Note: Certified copies of original qualifications must be obtained

Year obtained:

Qualification:

Special comments on post graduate experience:

Authorising Body:

Year obtained:

Qualification:


Authorising Body:

Year obtained:

Qualification:


Authorising Body:

Hospital Appointments within last ten years:

Dates: Hospital:

Itemise Postgraduate Educational Activity in the past three years:

Appointment:

Page 2


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 General Practitioner

Staff Specialist Dentist

Dental Specialist Consultant Emeritus

(No admitting rights)

Consultant Specialist/General Practitioner


House Medical Officer

(Resident, Registrar, Career Medical Officer)

Registered speciality/sub-specialties:

Surgical Assistant


Page 3


Surgical Assistant applicants only:

Name of accredited practitioner at each applicable hospital who will provide a reference for you.

Name Email Address, Rooms

Address & Mobile Phone

Hospital





Hospital

Hospital



Hospital



Hospital

Accreditation (Please tick):

Permanent Temporary from __________________ to _________________

<insert date> <insert date>

Page 4


Clinical privileges are sought in the field(s) of: (Not applicable to surgical assistants)

Anaesthesia







Adult

Cardiac

Paediatrics





Laparoscopic

Surgery

Paediatric

Paediatric Surgery

Neonatal

Infectious Diseases

Palliative Care

Cardiology





TOE

Diagnostic

Angiography







Interventional

Procedures

Angioplasty

EPS

Cardiothoracic

Surgery

 Adult

 Paediatric

Colorectal Surgery

 Laparoscopic

Surgery

Dental

Dental Specialist

Specify:

Intensive Care

Neonatology

Neurosurgery





Nuclear Medicine

Obstetrics and

Gynaecology









Adult

Paediatric

Gynaecology

General

Obstetrics

Gynaecology

Oncology

Advanced

Endoscopic Surgery

Occupational

Medicine

Pathology

Physicians/Internal

Medicine

 General Medicine

 Endocrinology











Geriatrics

Neurology

Renal Medicine

Respiratory

Physicians

Rheumatology

Plastic and

Reconstructive Surgery







Hand Surgery

Facio Maxillary

Surgery

Plastic,



Reconstructive

& Aesthetic Surgery

Head and Neck

Dermatology

Emergency Medicine

Oncology

 Medical Oncology

 Radiation Oncology

Ophthalmology





Adult

Paediatric

Psychiatry

 Sub-Specialty

Specify:

ENT Surgery







Adult

Paediatric

Paediatric



Endoscopic

Head and Neck

Oral and Maxillofacial

Surgery

 Facio Maxillary

Surgery

Radiology

Rehabilitation Medicine

Gastroenterology





Endoscopy

ERCP

Orthopaedics





Adult

Paediatric

Urology





Adult

Paediatric

Paediatric Medicine

Vascular Surgery

General Surgery

 Endoscopy

Page 5


Other privileges sought: (Not 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, email addresses and mobile telephone numbers of three 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. (Not applicable to surgical assistants)

Specialty:

Name of Referee 1: Name of Referee 2: Name of Referee 3:

Address:

Contact/ Mobile Number:

Address:


Address:

Contact / Mobile Number:

Specialty:

Name of Referee 1:

Address:

Contact /Mobile Number:


Address:


Are there any conditions attached to this registration?


Address:


Please record your current registration number with the relevant State Medical or Dental Board (as appropriate) and provide photocopy:

State(s): Number(s):

Yes No

If Yes, provide details of conditions:

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) eg full surgeon

Billing less than $(insert amount) (insert specialty)

Does your membership fully cover the types of privileges you have applied for?

Yes No

Page 6


Appointment at other hospitals or day procedures centres:

Current/past

Current/past

Current/past

Current/past

Membership of colleges and/or other relevant Associations:

1.

2.

3.

4.

Any additional information:

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?

Yes

If Yes, give dates and particulars:

Have you ever been convicted or found guilty of any criminal offence, including a drug- or alcohol-related offence?

Yes

No

No

Are you the subject of current or pending criminal charges?

Yes No

If you answered yes to any of the above, please provide full details. Or, if you prefer, provide the information in a sealed envelo pe marked ‘Confidential for medical director only’ appended to this application, and indicate here that additional information is provided separately in this manner.

Page 7


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: (Not applicable to surgical assistants)



I authorise the Hospital to include my details in the Hospitals

Specialist Directory

Yes No

Authority :



I hereby apply for accreditation at South Eastern & The Valley Private Hospitals with clinical privileges I have also specified.



In making this application I acknowledge and agree:

I have received a copy of the Healthecare Hospital By-Laws.

I will abide by the By-Laws, 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:

Please ensure that this form is fully completed and that the following documentation is included with this application:



Separate CV Attached (please note, your CV will be forwarded to the Medical Advisory

Committee at South Eastern & The Valley Private Hospitals, who will be asked to provide a recommendation regarding your application).



Certified Copy of Post Graduate Qualifications .



Certified Copy of College Fellowship .



Certified Copy of certificate showing participation in Continued Medical Education

(CME)/CPD



Certified Copy of current Medical Indemnity Certificate



Certified Copy of current certificate of Medical Registration .



Certified Copy of

Working With Children’s Check

(if applicable)



Copy of

Radiation Operator’s Licence

(if applicable).



Certified Copy of Police Check



Proof of Identity (certified coloured copies please)

Page 8


HEALTHE CARE AUSTRALIA PTY LIMITED

The Valley Private Hospital (ABN: 94 117 484 698)

& South Eastern Private Hospital (ABN: 71 117 484 536)

Authority to Obtain Registration & Insurance Details

Consent Form

I, ________________________________________, hereby give South Eastern Private and The

Valley Private Hospitals consent to obtain information relating to my insurance from my insurer and medical registration. This information will only be used for the purposes of providing evidence of insurance renewal. This consent will expire at the end of a period of five (5) years from signing of this letter.

Signature:__________________________________________________

Name:_____________________________________________________

Date of Birth:_______________________________________________

Address:___________________________________________________

__________________________________________________________

Specialty:__________________________________________________

Indemnity company: ________________________________________

Date:_____________________________________________________

Page 9


Proof of Identity

(Authorised officers should tick which proof of identity documents are supplied and initial).

The proof of identification checklist is based on the verification procedures set out in the Commonwealth’s Financial Transactions Reports Regulations

1988. Identification totalling 100 points or more must be produced by the applicant and sighted by an authorised officer.

Applicants must provide proof of identification from the list with a minimum total of 100 points. Identification must include:









at least one type of photo ID

proof of the applicant's name

applicant’s current residential address

applicant’s signature

 applicant’s date of birth.

All documents must be original. However, certified documents can be accepted where an applicant is interstate or overseas. These should be certified by an authorised person who can sign Statutory Declarations e.g. permanent employee of a Commonwealth, State, Territory or Local Authority who has five or more years of continuous service. A comprehensive list can be found at: http://www.ag.gov.au/statdec

Are you an Australian Citizen? If not, please provide proof of your current visa Yes No

CATEGORY A – to verify the name of applicant from one of the following

NOTE: Do not score additional points for more than one document

Points Copy

Attached

Initials of

Auth Off.

70 Current Australian Passport or expired Australian passport which has not been cancelled and was current within the preceding two years

Foreign passport with current Australian visa

N.B. working holiday and student visas only allow limited work rights, further information can be found at: http://www.immi.gov.au/managing-australias-borders/compliance/infoemployers/evo-orgs.htm#d

Other document of identity having the same characteristics as a passport (e.g. diplomatic documents and some documents issued to refugees)

Birth certificate (Australian or overseas, can be extract or full)

70

70

70

Australian citizenship certificate

Current Australian licence issued by Commonwealth, State or Territory, e.g.:

- Driver’s licence

- Boat licence

- Learner driver’s permit

Current identity card issued to a public employee

- Motorbike licence

- Provisional driver’s licence

- Firearms licence

Current student card issued by a tertiary education institution

70

40

40

CATEGORY B – to verify the name of the applicant (but only where they contain a photograph or signature)

Note: Additional documents can be awarded 25 points

40

Healthcare or pension card

Current Working With Children Check card

40

40

CATEGORY C – to verify the name of the applicant

Note: More than one document may be counted, but points scored from a particular source may be counted only once

Current Medicare/Private health insurance card

Foreign driver’s licence

Bank account details e.g. credit card/passbook/ATM card/cheque account (only one

per financial institution)

Marriage certificate (for maiden name only)

25

25

25

Australian divorce papers containing current and previous name

Taxation assessment notice (less than two years old)

PAYG payment summary with Tax File number (to be verified with employer)

CATEGORY D – to verify the name of the applicant

Legally drawn up mortgage papers

Current lease or tenancy agreement

25

25

25

25

Council rates notice (less than 12 months old)

Public utility account (gas, water, electricity or telephone – less than 12 months old)

Australian electoral roll card

Financial institution statement for current account (less than 12 months old)

Current Australian motor vehicle registration

CATEGORY E – to verify the name of the applicant and Date of Birth

25

25

25

25

25

25

25

Current membership card/registration certificate for union, trade or professional body/board

25

CATEGORY F – Special provisions only to be used if 100 point check cannot be met

For recent arrivals in Australia (6 weeks or less – proof of arrival date required) current passport

N.B The full 100 point check is required when the applicant has been in

Australia for longer than 6 weeks.

ABORIGINAL PERSON OR TORRES STRAIT ISLANDER RESIDENT IN AN ISOLATED

AREA. Identity of applicant ordinarily resident in an isolated area verified by TWO persons recognised as “community leaders” of the community to which the applicant belongs.

TOTAL (must equal 100 points or greater)

100

100

If the applicant’s name is different on any of the identification documents, evidence of the name change must be provided, for example, marriage certificate, divorce papers or deed poll documentation.

Name:

Authorised Officer for Proof of Identity

Signature:

Page 10

Application for Accreditation

Application for Accreditation

South Eastern & The Valley Private Hospitals

Consent Form

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Application for Accreditation