Appendix 3 Application Form General Practitioner

BALLARAT HEALTH SERVICES

RENEWAL APPLICATION FORM FOR CREDENTIALING AND DEFINING SCOPE OF PRACTICE FOR NON PROCEDURAL GPS PROVIDING RESIDENTIAL AGED CARE

Use this form for renewal applications to Ballarat Health Services.

Please refer to the BHS Protocol and Guideline for Credentialing and Scope of Practice for Senior Medical and Dental Professionals when completing this application http://www.bhs.org.au/node/361

Applicant’s name: First Name Middle Name Surname

2. Applicant Practice details

Date of Birth Professional Address

Postcode Preferred Postal Address (if different to Professional Address)

Postcode

Phone (BH)

Phone (AH)

Mobile / Pager

Contact e-mail address

Alternative e-mail address

NCP0140 Medical and Dental Staff Credentialing and Definition of Scope of Practice. Version5, June 2015 Page 1 NCP0140 Medical and Dental Staff Credentialing and Definition of Scope of Practice. Version5, June 2015 Page 2 4. Qualifications/credentials to support Speciality and Sub-speciality Primary specialty qualifications/credentials

Sub-specialty/s qualifications/credentials

4a. Advanced Scope of Practice Complete this section ONLY if applying for Advanced SoP Please refer to the BHS Guidelines and complete the section below for each Advanced SoP that you wish to apply for. Scope of Practice Supporting credential/qualification

4b. Reduced Scope of Practice

Complete this section ONLY if applying for Reduced SoP (Please refer to BHS Guidelines) Please outline the reasons for the proposed reduction of SoP

4c. Extension to Scope of Practice

Complete this section ONLY if applying for an extension to SoP (Please refer to BHS Guidelines) Please outline reasons for the proposed extension of Scope of Practice.

4d. Emeritus Medical Officer

Are you applying for Emeritus Medical Officer? Yes No

NCP0140 Medical and Dental Staff Credentialing and Definition of Scope of Practice. Version5, June 2015 Page 3 5. Provider/Prescriber Numbers

Do you have a Medicare Provider number for use at BHS? Yes No BHS Provider Number/s:

Do any restrictions apply? Yes No Please attach full details of any restrictions that apply.

Do you have a Prescriber Number? Yes No Prescriber Number:

6. Medical registration and other matters Please refer to www.ahpra.gov.au for definitions.

What is your AHPRA registration number?

Is this general registration? Yes No

Is this specialist registration? If yes, please specify: Yes No

Is this provisional registration? If yes, please specify: Yes No

Is this limited registration? If yes, please specify: Yes No Area of need Public interest Teaching or research If you have limited registration, and/or you are to be supervised or under a college peer-review process, please attach details of this process. Have you ever been formally disciplined (by an employer or other organisation) Yes No in the course of your work as a medical practitioner?

Have you ever been the subject of any prior disciplinary decisions or rulings Yes No imposed by any registration board in Australia or elsewhere?

Do you currently have or have ever had any conditions, restrictions, Yes No undertakings, reprimands or notations placed on your registration or your clinical practice either in Australia or any other country?

Have you ever had any conditions, restrictions, undertakings, reprimands or Yes No notations placed on your registration either in Australia or elsewhere?

Have you ever been denied a scope of clinical practice that you requested? Yes No

Have you ever chosen to reduce your scope of practice? Yes No

Has your right to practise ever been withdrawn, suspended, terminated or Yes No reduced by an organisation, employer or professional body?

NCP0140 Medical and Dental Staff Credentialing and Definition of Scope of Practice. Version5, June 2015 Page 4 Have you ever been convicted or found guilty of any criminal offence, including Yes No a drug or alcohol related offence?

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 envelope marked ‘Confidential for Medical Director only’ appended to this application, and indicate here that additional information is provided separately in this manner.

Are you registered as a medical practitioner in any other country? Yes No If yes, which country/s.

Have you ever been registered as a medical practitioner in any other country? Yes No If yes, which country/s

Do you have a current working with children check? Yes No This is required for staff regularly providing services to children in paediatric N/A wards. Working with children information can be found at: Card No: www.justice.vic.gov.au/wps/wcm/connect/justib/Working+With+Children/Homes Expiry date:

7. Medical Indemnity Insurance information

Current Private medical indemnity insurance cover (if applicable) Name of Insurer: Please attach a copy of current policy renewal certificate. New Policy Number: appointments need to attach a certified copy. Expiry date:

Is your proposed scope of private clinical practice reflected in or Yes No Not Applicable covered by your current medical indemnity insurance?

Have there ever been or are there currently pending medical Yes No indemnity claims, settlements or judgments against you?

Has your current or any previous medical defence Yes No organisation/insurer ever excluded or reduced any specific area of practice, or terminated or denied coverage?

If the answer to either of the above two questions is YES, please provide a detailed explanation and specify the name of the relevant medical defence organisation/insurer.

8. Continuing professional development AHPRA Have you met the continuing professional development requirements of AHPRA? Yes No Refer to AHPRA registration standard for details at: www.medicalboard.gov.au/Registration-Standards.aspx College / Society Have you met the CPD requirements of your College/Society? Yes No If annual process, please attach the current CPD certificate.

NCP0140 Medical and Dental Staff Credentialing and Definition of Scope of Practice. Version5, June 2015 Page 5 If triennial process, please provide the current triennial certificate and a copy of past 12 months lodgement. 9. Health and support considerations

Do you have a disability/health issue that: Yes No  may impact on your ability to perform any of the cognitive and physical functions that would fall within the scope of practice that you are seeking in this application?  may require special equipment, facilities or work practices to enable you to perform any aspect of the scope of practice you are seeking in this application?, or  might be relevant to determining your scope of practice? If you answered YES, please provide details of the disability or health issue and its likely or possible impact or your ability to carry out the sought scope of practice. Details of any special equipment facilities or work practices required should be included. This information can be provided on this form or, alternately, you can provide the information in a sealed envelope marked “Confidential for medical director only” appended to this application. Indicate here if additional information is being appended. This information is sought to enable an assessment to be made as to whether you can safely perform the inherent and reasonable requirements of the work that you seek to perform at Ballarat Health Services or whether any reasonable adjustments might be required to ensure you can work at Ballarat Health Services in a way that ensures patient safety.

10. Agreement/undertakings I understand that in assessing my application the health service will make additional enquiries as to my suitability for the position. I understand the health service will conduct a routine police check. Yes No I authorise the health service to seek information as to my past experience, performance Yes No and current fitness to practise from my referees. I agree to familiarise myself with relevant hospital by-laws, policies and procedures and to Yes No abide by them. I accept that the health service will obtain information relevant to my application from the Yes No Medical Board of Australia, AHPRA and any other authority that regulates health practitioners. I authorise the health service to obtain information relevant to my application from my Yes No current and any previous medical indemnity organisation/insurer. I authorise the health service to obtain information relevant to my supervision requirements Yes No (where applicable). I authorise the health service to seek information from other persons as the health service Yes No considers appropriate, including any relevant health service, college or other professional organisation. I agree to abide by the organisation’s and state and national confidentiality and privacy Yes No laws and policies and understand that breaches may result in the cessation of my appointment. I agree to notify the Director of Medical Services/Clinical Director at Ballarat Health Yes No Services of any event/situation which may impact on my ability to exercise my scope of clinical practice, whether it be due to medical registration matters, or otherwise. This includes matters about which I consider that the Director/Clinical Director would wish to be informed and, as a minimum, includes the kinds of information covered in this application (such as any criminal charges or convictions, or reductions in registration or insurance).

NCP0140 Medical and Dental Staff Credentialing and Definition of Scope of Practice. Version5, June 2015 Page 6 I agree to participate in this health service’s performance development and support Yes No process (Partnering for performance or equivalent) I agree to promptly notify the Director of Medical Services/Clinical Director of any adverse Yes No clinical incident I am involved in or become aware of. I agree to work within my defined scope of clinical practice and to make a further Yes No application should I seek to extend the scope of clinical practice granted to me. Should any question as to my scope of clinical practice arise, I agree that the health Yes No service may make such enquiries as it considers necessary to assess whether that scope of clinical practice is appropriate. I have accessed the BHS Senior Medical Staff Orientation Handbook Yes No

11. Declaration (When submitting this application form electronically, please print and sign this page and return with the other attachments). I hereby declare that the information contained in this application is true and correct in every respect.

Name of Applicant …………………………………………………………

Signature of Applicant ………………………………………………………… Date ……………………………

If for any reason you are unable to sign the declaration above, please explain the circumstances.

Please note:

1. The information collected on this form will be used by Ballarat Health Services Medical Credentialing and Appointments Committee to assist in the determination of your application.

2. The information collected on this form will be stored on a secure BHS database and will be subject to Audits

3. Information provided on this form will not be used or disclosed for any other purpose.

4. Ballarat Health Services operates in accordance with Federal and State Privacy Legislation including adherence to the National Privacy Principles.

5. Copies of Ballarat Health Services Privacy and Confidentiality Policies are available upon request.

12. Checklist Please check that you have completed all sections in this application form including providing attachments as incomplete applications will be returned to you for completion.

Please check that the following attachments are included:

Copy of current Medical Indemnity Insurance Certificate

Continuing Professional Development Certificate (CPD) from specialist College or Society

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