Government of Western Australia
MEDICAL PRACTITIONER TEMPORARY
APPOINTMENT AND
CREDENTIALLING APPLICATION FORM
Department of Health
(INSERT HOSPITAL/HEALTH SERVICE
NAME) Area Health Service
FORM 1.2
Section 1
SURNAME
FIRST NAMES
DATE OF BIRTH
OTHER FAMILY NAME:
(Please include any other family names that appear on
certificates)
HOME ADDRESS
SUBURB
POST CODE
TELEPHONE No
MAIN PRACTICE ADDRESS
SUBURB
POST CODE
TELEPHONE No
FAX No
MOBILE / AFTER
HOURS CONTACT No
1.
EMAIL ADDRESS:
PAGER No
2.
Section 2
SPECIALITY
SUB SPECIALTY
Section 3
Details of scope of practice sought by
applicant in relation to the job description
(If applicable, please complete
Scope of Clinical Practice form)
Identify procedures outside of the job description
attached
Section 4
PROPOSED LOCATION(S) OF PRACTICE
(Health Service to fill in appropriate Health Sites/Hospitals)
Tick where applicable
Provider Number
Prescriber number:
1
Section 5
Please attach your curriculum vitae which must be current and should include a comprehensive
list of your appointments and scope of clinical practice held at other health care facilities
(including location, nature and duration and whether any restrictions have been placed on your
scope of clinical practice)
Section 6
MEDICAL BOARD REGISTRATION
Supply evidence you are eligible for Specialist registration with the Medical Board of Australia
under the Medical Practitioners Act 2008 and whether there would be any conditions attached to
the registration which would limit your ability to fulfil the requirements of the position.
If you have current Medical Board Registration, please supply your Medical Board Registration
Number and Australian State of registration:
__________________________
Section 7
Attach certified copies of your undergraduate and postgraduate qualifications, if not currently
registered with the Medical Board of Australia
Section 8
Residential Status
Are you an Australian Citizen?
Yes
No
If No,
Please supply details of a valid visa, residential status, and current documentation.
2
Section 9
TWO PROFESSIONAL NOMINEES
Please note that written confidential referee reports will be obtained and verbal reference checks
may also be undertaken
1. Name, Address, Telephone and Email
2. Name, Address, Telephone and Email
Section 10
Please confirm (tick) you have the following
Criminal Records Screening
(copy required)
clearances:
Yes
Number and expiry date…………………
Screening is a mandatory requirement for
No
engagement/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 11
I declare that I have no prior or current disciplinary orders, professional sanctions, criminal convictions,
misconduct or suspicion of misconduct or any matters reportable under the Medical Practitioners Act 2008.
Signed:……………………………
Date: ………………………………
Or, if you do have prior or current disciplinary orders, professional sanctions, criminal convictions,
misconduct or suspicion of misconduct or any matters reportable under the Medical Practitioners Act 2008.
Please give details:
Signed:……………………………
Date:……………………………….
Section 12
Please attach evidence of accreditation or endorsement of specialist medical colleges for the
provision of specific clinical services, procedures or other interventions:
3
Section 13
Evidence of the type and scope of current Professional Indemnity Insurance, if Arrangement B
(Medical Practitioner with private rooms outside of the hospital)
Have you already signed an agreement to be provided with Medical Indemnity by the State?
Yes
No
If yes, at which Health Service?
Section 14
Evidence/details of participation in CPD/MOPS program:
Section 15
SIGNED CONSENT AUTHORISATION and DECLARATIONS to facilitate Appointment,
Credentialling and Scope of Practice processes:
1. I authorise the Credentialling Committee to obtain details about my past performance,
which may include information on the following: evidence of participation in clinical
governance activities, undertaking continuing medical education, participation in
teaching and research, other evidence deemed appropriate by the health care facility to
demonstrate the provision of clinical care
2. I authorise the health care facility to obtain relevant information from a professional
registration organisation that relates to any conditions placed on practice and the nature
of any unresolved complaints.
3. I confirm and I understand that all appointment documents will be kept in my personnel
file and any further information gathered as part of the credentialling and scope of clinical
practice process will also be retained on file.
4. I consent to the health care facility to obtain, retain and share credentialling information
within WA Health.
and
I declare:

I have no physical or mental condition or substance abuse problem that could affect my
ability to perform the scope of clinical practice sought

All information provided is accurate at the time of application
SIGNED………………………………………….
DATE……………………………………………..
4
(To be completed by Employer)
Temporary practice arrangements
PRACTITIONERS NAME
CONTACT PHONE NUMBER
ADDRESS
Temporary practice arrangements are granted to this medical practitioner
LOCATION (S)
CREDENTIALS
SPECIALTY/POSITION
MEDICAL BOARD REGISTRATION
GENERAL LIST OF PROCEDURES
ADDITIONAL PROCEDURES
TEMPORARY
CREDENTIALLING
DATES: (NB MAXIMUM 3 MONTHS)
VISA DOCUMENTION
(If applicable)
Approved by:_____________________________________________________
DIRECTOR:________________________DATE__________________________
5