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ANNEXURE B

MEDICAL/DENTAL APPLICATION FORM FOR INITIAL ACCREDITATION & CLINICAL PRIVILEGES AS A MEDICAL PRACTITIONER
AT............................................................HOSPITAL
If you wish to apply to other UnitingCare Health hospitals please send a separate application form directly to the Director of Medical Services at each hospital. Please indicate below if you already hold clinical privileges at any other UnitingCare Health hospitals. The Wesley Hospital Auchenower St Stephens Hospital Maryborough St Stephens Hospital Hervey Bay St Andrews War Memorial Hospital, Spring Hill The Sunshine Coast Private Hospital, Buderim

CategorY of Accreditation Sought: 1. Visiting Medical Practitioner: Specialist General Practitioner Emeritus Consultant Consultant General Practitioner Personal Details Given name/s (in full): Staff Specialist Staff General Practitioner Dentist Consultant Specialist

Surname: Former name (including maiden name): Date of birth: (optional)

Gender:

Male

Female

Name of spouse or partner (optional for hospital invitation list only): Name and contact details of person to inform in case of a personal emergency Name: Please tick one box for your preferred mailing address Residential Address: Tel: Email: Professional Address (primary consulting rooms): Tel: Email: HIC Provider No: Fax: Pager (Tel): HIC Prescriber No: Mobile: Pager No: Fax: Mobile: Tel: Mobile:

Please list your after-hours contact preference, in order of priority (Home, Mobile, Pager) 1.____________________________________ 2.____________________________________ 3.____________________________________

Qualications (include primary degree, fellowship, diploma, etc) Name of Degree/Fellowship Authority/Awarding Body Year Obtained

Please list special professional interests:

ANNEXURE B

2.

ADDITIONAL INFORMATION

Please provide the following information either in your attached Curriculum Vitae or on a separate sheet. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Undergraduate qualication/s, post graduate qualication/s, degrees, diplomas, college or professional qualication/s (name of qualication, authorising/awarding body, year obtained). Past (up to 10 years) and current hospital or day procedure centre appointments/employment (date to and from, hospital or doctor, position appointment/employment). Itemise post graduate educational activity in the past three years. Nature of current practice, place of work and special professional interests. Research activities, funded projects, quality assurance and continuous professional development activity (eg EMT, MOPS, etc) during the past three years. Publications. Registered specialty/sub-specialties. Where available, objective data on the outcomes of clinical activity. Details of current involvement in clinical audits, peer review activities, other quality activities. Membership of professional associations.

11.

Are you currently involved in a recognised speciality college or other formal CME/PD program? If no, please detail your current arrangements to ensure currency of your clinical practice:

No

Yes (please attach evidence)

12.

Are you currently enrolled in a clinical audit/quality assurance activity/peer review?

No

Yes (please attach evidence)

If no, please detail your current arrangements to ensure the maintenance of the standard of your clinical practice:

3.

ACCREDITATION STATUS

Clinical privileges (scope of clinical practice) being sought should be indicated on the attached Clinical Privilege (Scope of Practice) Fields Form. Please note that the hospital may not be able to allocate clinical privileges or clinical privileges with admitting rights for all these specialties or sub-specialties. Accreditation sought in the following category (please tick one): Clinical Privileges with Admitting Rights Clinical Privileges without Admitting Rights

Please list current appointments that would continue concurrently at other health care organisations. Facility Credentialed In

Other Licences (e.g. Laser, Radiation).

ANNEXURE B

4.

REFEREES

Include three referees who can attest to your recent practice, at least one of whom is not professionally or nancially related to you; one of whom, where possible, is a Visiting Medical Practitioner at the relevant hospital; and at least one of whom, where possible, is a senior administrator at a hospital at which you already have an appointment. You do not need to complete this section if you have provided this information in your Curriculum Vitae.

Speciality/Sub-speciality/Interest 1. Tel: 2. Tel: 3. Tel: Name of Referee Mobile: Fax: Name of Referee Mobile: Fax: Name of Referee Mobile: Fax:

5.

INSURANCE

Please provide a copy of your current certicate of renewal, including practice category details, (where available) of your medical indemnity/professional indemnity insurance provider, income limit and cover.

Name: Expiry Date of cover:

Membership/Policy No: Category of coverage:

Has your professional indemnity insurer/fund ever applied conditions or refused to renew your cover or membership? If yes, please provide details:

No

Yes

6.

REGISTRATION

Please provide a copy of your current registration certicate with the Queensland Medical/Dental Board (as appropriate).

Are there or have there ever been any conditions, undertakings, or any offer of undertakings attached to your registration: If yes, please provide details:

No

Yes

Have your clinical privileges (scope of clinical practice) 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? No Yes If yes, please provide details:

Have there ever been any adverse ndings made against you which would be relevant to your appointment (for example: breach of relevant health insurance laws, professional misconduct, sexual assault or assault) by the Health Insurance Commission, a Medical Board, a Health Rights Commissioner/ body, a Coroner, a Court, or any other professional disciplinary or similar body? No Yes If yes, please provide details:

ANNEXURE B

Additional information you may wish to provide in support of your application:

7. AUTHORITY/DECLARATION

I authorise UnitingCare Health, its employees, ofcers and the Medical Advisory Committee to obtain information on an annual, or as necessary, basis from the registration body/indemnity insurance organisation as nominated in this application, regarding the currency of my registration/membership of that authorised body/organisation. I authorise UnitingCare Health, its employees, ofcers and the Medical Advisory Committee to seek information as to past experience, performance, Competence and Current Fitness, with scope of clinical privileges sought. I authorise/do not authorise UnitingCare Health to include my name and practice details in any hospital/s or UnitingCare Health specialist directory. I authorise UnitingCare Health to conduct a criminal record check in respect of my history including information relevant to the provision of services to children and I agree to notify the General Manager if I am convicted of a sex or violence offence or any other offence relevant to my practice as a Medical Practitioner. In applying for appointment I acknowledge that I have read the By-Laws and I agree that I will comply with the By-Laws (including any annexure or variation to the By-Laws during the tenure on my appointment), policies and rules of UnitingCare Health and any of its hospitals and any terms and conditions which are attached to my appointment by the General Manager, and all legislative requirements. I undertake to notify UnitingCare Health promptly and in writing if my clinical privileges or appointment are altered at any other hospital or day procedure centre. I certify that I have the required Competence and Current Fitness to be able to undertake the clinical privileges that I have applied for. I agree to participate in the Medical Association, where convened by the Facility. I agree to participate in quality, safety and risk management programs and training as required by UnitingCare Health. I agree to participate in any clinical quality assurance activity including submitting my practice to clinical audit and peer review, in conjunction with the hospital, the Medical Advisory Committee or clinical speciality committees. I have read the Medical Board of Queenslands Medical Practitioners Infected with Blood Borne Viruses (Oct 2001 and as amended) and Queensland Healths Infection Control Guidelines (Nov 2001 and as amended) policies and agree to abide by the requirements of those policies. I undertake to notify UnitingCare Health should any information provided in this application for appointment vary in any way. I acknowledge that I have read the UnitingCare Health Code of Conduct and I agree that I will comply with the Code of Conduct. I declare that my medical indemnity/professional indemnity cover is adequate and appropriate for the Clinical Privileges and activity which is the subject of this application. I acknowledge and agree to release the Relevant Hospital and authorised persons from and against all claims out of a decision to suspend or terminate my Accreditation or to not re-appoint me in circumstances set out in By-laws [By-law 11]. I declare that the statements contained in this application are correct. Name Signature NOTE: Please attach the folloWing A copy of your Curriculum Vitae; Evidence of registration with the Medical/Dental Board of Queensland (as appropriate); Evidence of medical indemnity insurance and/or declaration of adequate cover; Evidence of CME/PD Program; Evidence of Clinical Audit/Peer Review; A passport size photograph of yourself (photocopy of drivers licence (with photo) accepted). Your application and reasons for decision as to whether to accredit will be maintained for a period of seven years. Please return this form and attachments to the relevant hospital Director of Medical Services. For Ofce Use Only: Received ...../...../..... Interview ...../...../..... MAC ...../...../..... Notied ...../...../..... Date

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