application for appointment, credentialing and …...application form – general practitioner page...

Application Form – General Practitioner of 14

Application for Appointment, Credentialing and Clinical Privileges of Visiting General Practitioners

1. Applicant and contact details

Primary Facility Honorary Yes £ No £ Title & Surname

Given Name/s Previous Name

Please include your previous name if it appears on certificates

Date of Birth Country of Birth

Residency status: Australian Citizen

Permanent Resident of Australia

Yes � No �

Yes � No � If No - List details of your current valid visa approval (include

a copy with your application) Professional Address

Postcode

Phone (BH) Phone (AH)

Fax Mobile Pager

e-mail address Postal Address (if different to

Professional Address above)

Postcode

Private Address

Postcode

This form sets a minimum information standard , however, information can also be provided

by the provision of a current curriculum vitae where indicated.

Please note: If you need to correct any error in your application, please initial the correction. Please attach to this form:

• Current curriculum vitae • Applicants who have not held previous appointments with this health service

must provide certified copies of all original qualifications • Copy (copies) of current medical registration • Copy of current medical indemnity insurance certificate (if applicable) • Copies of relevant Visa documents (if applicable)


2. Application for Clinical Privileges

Introduction The purpose of delineating the privileges of medical staff is to ensure a high standard of patient care by matching the work that a practitioner wishes to perform with demonstrated skill and competence in a hospital with the delineated role of the hospital.

Below are suggested privileges considered appropriate for general practice.

It is understood that training and experience can vary considerably and any general practitioner who feels that relevant experience equips him or her to undertake procedures not listed should enter these in the space provided and describe briefly their special training in these areas.

The Credentials Committee will consider all of the clinical privileges requested in your application. The clinical privileges granted will take into consideration the delineated role of the hospital or service and its support capabilities.

Previous clinical privileges denied

(a) Have you ever been denied a defined scope of clinical practice? Yes £ No £

(b) Has your right to practise ever been withdrawn, suspended, terminated or reduced? Yes £ No £

If you answered YES to either of the above questions, please provide full details.

Please attach any supporting documentation or data that will assist the Credentials Committee to consider your application.

Outline nature of clinical privileges sought (may be more than one):

GP anaesthesia � GP obstetrics �

GP emergency medicine � GP orthopaedics �

GP general surgery � GP paediatrics �

GP medical � Other �

GP mental health �

Details are to be specified on following pages where relevant. Please note that the Position Description specifies the clinical and other duties expected of all General Practitioner Visiting Medical Officers. For example, this could be:

1. Participate in the one in ten 24-hour ‘Doctor of the Day’ general practitioner roster to provide:

• Medical services to patients of the Emergency Department; • After-hours on-call to all admitted patients of the hospital; and • Admission and ongoing care of patients.


2. Provide medical services to patients who are admitted under the GP Visiting Medical Officer.

3. Participate in multi-disciplinary case conferences.

Please list the Facility or Facilities for which you are applying: Facility Name Provider Number

Primary Facility

Facility 2

Facility 3

Facility 4

Facility 5

Anaesthesia

Other than for local anaesthesia, specific clinical privileges in this area must be requested. If requested, clinical duties will involve the administration of anaesthetics to low risk patients. Subject to the role delineation of the hospital and experience, new applicants should be able to demonstrate completion of a training program for anaesthesia consistent with the Australian and New Zealand College of Anaesthetist guidelines for general practice anaesthesia. Applicants for reappointment will be required to demonstrate their compliance with the guidelines regarding caseloads and continuing medical education activities.

If privileges are requested in this area, please indicate below and support the application with evidence of your experience and training. Clinical Privileges Sought

Emergency Medicine Subject to the role delineation of the hospital and experience, a general practitioner may:

• Manage patients with minor injuries and ailments; and • Provide resuscitation and stabilisation of patients prior to their transfer to

higher levels of care. If further privileges are sought in emergency medicine, please indicate below the clinical privileges requested and support the application with evidence of your experience and training. Additional Clinical Privileges Sought


General Surgery Subject to the role delineation of the hospital and experience, a general practitioner may perform minor surgical procedures.

• Removal of cutaneous and subcutaneous lesions, e.g. BCCs, sebaceous cysts and lipomata.

• Drainage of simple abscesses. • Surgical treatment of ingrown toenail.

If further privileges are sought in general surgery, please indicate below the clinical privileges requested and support the application with evidence of your experience and training.

Additional Clinical Privileges Sought

General Medicine Subject to the role delineation of the hospital, a general practitioner may admit and manage medical inpatients. Patients with a range of acute and chronic health presentations may be admitted to rural hospitals. Patients with serious acute or complex internal medicine problems may be admitted under networked arrangements or in consultation with an appropriate specialist physician.

If further privileges are sought in general medicine, please indicate below the clinical privileges requested and support the application with evidence of your training (e.g. Fellowship in Advanced Rural General Practice/Graduate Diploma in Rural General Practice) and experience (e.g. Advanced Rural Skills Post in adult internal medicine). Additional Clinical Privileges Sought

Mental Health Subject to the role delineation of the hospital and experience, a general practitioner may manage inpatients with mental health conditions that do not need to be in designated or gazetted mental health beds.

If further privileges are sought in mental health, please indicate below the clinical privileges requested and support the application with evidence of your experience and training.



Obstetrics Specific clinical privileges in this area must be requested. Subject to the role delineation of the hospital and experience, a general practitioner may:

• Manage obstetric patients only if they possess a Diploma of Obstetrics or equivalent and agree to conform to guidelines developed jointly by the: - Royal Australian College of General Practitioners (RACGP), and - Royal Australian & New Zealand College of Obstetricians and Gynaecologists

(RANZCOG); or • Manage obstetric patients as part of shared-care arrangements with specialist

obstetricians. Applicants for reappointment will be required to demonstrate their compliance with these guidelines and continuing medical education activities. If privileges are requested in this area, please indicate below and support the application with evidence of your experience and training.

Clinical Privileges Sought

Orthopaedics Subject to the role delineation of the hospital and experience, a general practitioner may manage uncomplicated and simple fractures.

If further privileges are sought in orthopaedics, please indicate below the clinical privileges requested and support the application with evidence of your experience and training.


Paediatrics Subject to the role delineation of the hospital and experience, a general practitioner may attend paediatric inpatients in accordance with the relevant NCAHS Management of Paediatric Emergency Department Presentations and Admissions within Paediatric Medical Role Delineation Levels 1 – 3 Policies. Refer NC-Area-Pol-2945-07, 2946-07, and 2947-07.

If further privileges are sought in paediatrics, please indicate below the clinical privileges requested and support the application with evidence of your experience and training.


Other

Other clinical privileges may be requested e.g. sexual assault services, drug & alcohol services, etc.

If other clinical privileges are requested, please indicate below and support the application with evidence of your experience and training. Clinical Privileges Sought


3. Qualifications * Can be detailed in CV

Qualifications University/Organisation Year obtained

For applicants who have not held appointments in this health service, please provide certified copies of qualifications or evidence of qualifications obtained

4. Other training and clinical experience * Can be detailed in CV With respect to your response to Section 2, please provide details of clinical experience and post-qualification training. Include the title of course/s undertaken, the organisation offering the course, and the qualification obtained.

Privilege Sought Training and Experience Clinical Privileges

Requested Yes/No

Anaesthesia

Yes £ No £

Emergency Medicine

Yes £ No £

General Surgery, other than minor surgery listed above

Yes £ No £

General Medicine

Yes £ No £

Mental Health

Yes £ No £

Obstetrics

Yes £ No £

Orthopaedics

Yes £ No £

Paediatrics

Yes £ No £

Other – please list below:

Yes £ No £

Yes £ No £


5. Clinical appointments * Can be detailed in CV Provide details on all current and previous public and private clinical appointments during the past five years (including names of organisations and dates of appointment), or other places of practice (for example, general practice).

Organisation Term of appointment

Main appointment:

to

Other appointments: to

to

to

to

to

to

to

to

6. Academic appointments/teaching experience * Can be detailed in CV Provide details of current and previous teaching appointments (including names of organisations and dates of appointment).

Organisation Status/Level Term of Appointment

to

to

to

to

to

to

to

to

to


7. Continuing medical education/continuing professional development (a) Provide details of your involvement in continuing medical education/continuing professional

development. Include the name of the college/organisation program in which you are enrolled.

(b) Please attach current re-certification statement or certificate from the relevant college or advise of CPD activities, college based and other, undertaken in the last three years.

(c) Have you satisfied the continuing medical education/continuing professional development requirements of your college membership/ fellowship?

Yes £ No £

8. Clinical review/peer review Do you regularly participate in formal quality and peer review activities? Yes £ No £

Provide details of such quality/peer review activities.


9. Grand rounds/health service educational activities (a) What educational training activities for junior staff have you participated in over the past three years?

(b) Are you prepared to conduct a grand round or other educational activities, for example, on a once a year basis?

Yes £ No £

10. Have you any other information to support this application

11. Regulatory and indemnity information

(a) Australia Health Practitioner Regulation Agency registration

Is this registration temporary?

If yes, provide details.

(Attach a copy of current Registration Certificate)

Registration number:

Yes £ No £

(b) Does your registration pertain to an area of need? If so, please detail the type of assessment process undertaken prior to registration.

Yes £ No £

(c) Are you registered as a medical practitioner in any other country? If so, please specify.

Yes £ No £

(d) Do you have any conditions or restrictions placed on your registration (either in New South Wales or elsewhere)? If so, please provide full details

Yes £ No £

(e) Do you have a medical board appointed supervisor? If so, please provide details (including name and location of supervisor and frequency of supervision)

Yes £ No £

(f) In the past, have you ever had any conditions or restrictions placed on your registration (either in New South Wales or elsewhere)? If so, please provide full details

Yes £ No £

(g) Current medical indemnity cover (if applicable)

Attach a copy of current policy renewal certificate.

Expiry date of current policy:

(h) Is your proposed clinical privileges reflected in or covered by your current medical indemnity insurance?

Yes £ No £ N/A £ (only if covered by TMF)


(i) Over the past 10 years, has there been or are there currently pending any claims, settlements or judgments against you?

Yes £ No £

(j) Has your current or any previous medical defence organisation/insurer ever excluded or reduced any specific area of practice, or terminated or denied coverage?

Yes £ No £

(k) 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.

(l) Is your Provider Number subject to any restrictions? Provider Number to be recorded in section 2 (b)

If YES, please provide full details.

Yes £ No £

(m) Do you have a Prescriber Number?

Prescriber Number:

If YES, is it subject to any restrictions?

If restrictions apply, please provide full details.

Yes £ No £

Yes £ No £

12. Health status Do you have a disability/health issue that:

• may impact on your ability to perform any of the cognitive and physical functions which 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?

Yes £ No £

If yes, please provide details of the disability/health issue, its impact on your ability to carry out the scope of practice sought, and details of any special equipment facilities or work practices required.

This information can be provided on this form or, if you prefer, you can provide the information in a sealed envelope marked ‘CONFIDENTIAL for Director of Medical Services ONLY’ appended to this application, and indicate here that additional information is provided separately in this manner.

This information is sought to enable an assessment to be made as to whether you can safely perform the inherent/reasonable requirements of the work which you seek to perform at the facility/facilities by submitting this application, or whether any reasonable adjustments might be required to ensure that you can work in a way that ensures patient safety.


13. Disclosure about disciplinary actions/criminal activity

(a) In the last 10 years, have you been the subject of disciplinary action in the course of your work as a medical practitioner?

Yes £ No £

If YES, please describe.

(b) In the last 10 years, have you been the subject of disciplinary action or professional sanctions imposed by any registration board whether in New South Wales or elsewhere?

Yes £ No £


(c) In the last 10 years, have you been the subject of any investigation, inquiry or findings by any registration board (whether in New South Wales or elsewhere) in relation to your ability to practise or have direct patient contact, or regarding your professional performance or your professional conduct?

Yes £ No £


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

Are you the subject of pending criminal charges?

Yes £ No £ Yes £ No £

If YES to any of the above, please provide full details or, if you prefer, provide the information in a sealed envelope marked ‘CONFIDENTIAL for Director of Medical Services ONLY’ appended to this application, and indicate here that additional information is provided separately in this manner.

(e) In the last 10 years, have you ever had any adverse findings made against you that may be relevant to your appointment (in addition to anything you may have noted above)?

Yes £ No £

If YES, please provide full details.

If you require further space to answer any questions, please attach separate pages, identified with the relevant section number.


14. Referees Please provide details of three independent professional referees, preferably at least two in your specialty, one of which is your current supervisor or manager, who have been in a position to judge your qualifications and experience during the past five years and who have no conflict of interest in providing a reference.

Referee 1 Name

Position held currently

Professional address

Postcode

Phone (BH)

Phone (Mobile)

Fax

e-mail address

Referee 2 Name



Postcode

Phone (BH)

Phone (Mobile)

Fax

e-mail address

Referee 3 Name



Postcode

Phone (BH)

Phone (Mobile)

Fax

e-mail address


15. Agreement/Undertakings I understand that in assessing my application for appointment as a visiting medical practitioner, the health service will make additional enquiries as to my suitability for the position.

(a) I authorise the health service to conduct a criminal record check in relation to my history.

Yes £

No £

(b) I authorise the health service to obtain information relevant to my application from the Medical Council of New South Wales, the Australian Health Practitioner Regulation Agency and any other board regulating health practitioners, whether in New South Wales or elsewhere.

Yes £

No £

(c) I authorise the health service to obtain information relevant to my application from my current and any previous medical indemnity organisation/insurer.

Yes £

No £

(d) I authorise the health service to obtain information relevant to my supervision requirements (where applicable).

Yes £

No £

(e) I authorise the health service to seek information as to my past experience, performance and current fitness from my referees and from other persons as the health service considers appropriate, including the NSW Health Care Complaints Commission, any relevant health service, college or other professional organisation.

Yes £

No £

(f) I authorise access to the above information by representatives of the health service’s credentialing committees.

Yes £

No £

(g) If appointed, I agree to familiarise myself with relevant Area Health Service by-laws, policies and procedures and the NSW Health Code of Conduct and to abide by them.

Yes £

No £

(h) If appointed, I agree to abide by confidentiality and privacy obligations and understand that breaches may result in disciplinary actions which could lead to the cessation of my appointment.

Yes £

No £

(i) I agree to notify the Director of Medical Services/medical leader 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/medical leader 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, reductions in registration or insurance).

Yes £

No £

(j) If appointed, I agree to comply with relevant ongoing educational/certification programs of my college/association/joint consultative committee and to furnish details to the health service on an annual basis as requested by the Director of Medical Services/medical leader.

Yes £

No £

(k) If appointed, I agree to participate in annual service review. Yes £

No £

(l) I agree to promptly notify the Director of Medical Services/medical leader through the Incident Information Management System (IIMS) of any adverse clinical event I am involved in or become aware of.

Yes £

No £


(m) If appointed, I agree to work within my defined clinical privileges and to make a further application should I seek to extend the clinical privileges granted to me.

Yes £

No £

(n) If appointed, should any question as to my credentialing or clinical practice arise, I agree that the health service may make such inquiries as it considers necessary to assess whether that credentialing or my clinical privileges are appropriate.

Yes £

No £

Declaration As recommended under the Standard for Credentialing and Defining the Scope of Clinical Practice of the Australian Commission for Safety and Quality in Health Care with respect to the information required for initial credentialing of a medical practitioner, the health service requires that the following declaration is completed by applicants.

I hereby declare that I have not been subject to any prior change to the defined clinical privileges or denial, suspension, termination or withdrawal of the right to practise (other than for organisational need and/or capability reasons) in any other organisations and that I have not been subject to any prior disciplinary action or professional sanctions imposed by any registration board.

I hereby declare that the information contained in this application is true and correct.

Signature of Applicant ………………………………………………………… Date ……………………………… Please note: If for any reason you are unable to sign the declaration above, please explain the circumstances.

application for appointment, credentialing and …...application form – general practitioner page...

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