Renewal Application Form – Townsville Day Surgery

Personal and Contact Information

Name*

Given Names Surname

*

Prefix Preferred Name

Any former names including maiden name

Date of Birth

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Mobile Phone Home Phone Pager Fax

Email Address

Personal Business

Provider Number Prescriber Number

Emergency Contact

Name Relationship Phone 1 Email

Name of Partner/Spouse

(for Hospital invitation list)

Professional Practice Details

Practice Name (1)

Business Address (Primary Consulting Room)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Fax

Practice Name (2)

Business Address (Other Consulting Rooms)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Fax

Professional Registration Details

Please attach a copy of your Registration certificate

Registration Number Category of Registration Expiry Date

Are there any conditions or undertakings currently attached to this registration?

Yes
No

If yes, please give details

Have you ever been subject to an adverse finding or had conditions or undertakings attached to you registration by a medical board, dental board or other registration board (as appropriate)?

Yes
No

If yes, please give details of the restriction and what period during which the restrictions apply/applied.

Professional Indemnity

Please attach a copy of your professional indemnity certificate)

Name

Indemnity Insurance Number Category of Coverage Insurance Company

Does your membership fully cover the scope of clinical practice you have applied for?

Yes
No

Has your medical defence insurer or any medical defence insurer or fund of which you have been a member ever applied conditions or refused to renew your cover or membership (in part or in full)?

Yes
No

If yes, please provide details

Are there any current claims for compensation against you or complaints lodged with the Medical Board (or other Registration Board) or Health Quality & Complaints Commission (HQCC)?

Yes
No

If yes, please provide details

Have there ever been any adverse findings made against you which would be relevant to your appointment (for example: breach of insurance/medical laws, professional misconduct, sexual assaults or assault) by the Health Insurance Commission, a Medical or Registration Board, a Health Care Complaints Commission/Body, a Coroner, a Court or any other negligence, professional, disciplinary or similar body?

Yes
No

Criminal Record Check – Have you been convicted of, or pleaded guilty to a criminal offence including a serious sex or violence offence or an offence involving dishonesty or drugs (other than a spent conviction)?

Yes
No

If yes, and if not prevented by confidentiality agreements, could you please provide a brief description of each adverse judgement or settlement, and the year in which the event occurred?

* This information is required to assess an application for scope of clinical practice and will only be used by Townsville Day Surgery for such purposes. Information provided will not be disclosed otherwise.

Please nominate a Medical Practitioner accredited at the Hospital in your Specialty available for contact by the Hospital in the case of an emergency if you are unavailable, and who has agreed to deputise for you.

Name Specialty Contact Number

Clinical Practice sought in the following category(s)

Priveleges Sought

Detail the scope of Clincal Practice Requested (Not applicable to Surgical Assistants)

Anaesthesia

Adults
Cardiac
Neonatal
Obstetric
Other (please specify)

Cardiac Surgery

Adult

Dental

Oral & Maxillofacial

Dermatology

Adult

Emergency Medicine

Adult

Endocrinology

Adult

ENT Surgery

Adult
Head and Neck

General Surgery

Adult
Endoscopy
Laparoscopic Surgery
Other (Please specify)

Gynaecology

Gynaecology General
Uro-gynaecology
Ultrasound
Advanced Endoscopic Surgery
Laparoscopic Surgery
IVF
Other (Please specify)

Medical Imaging

Adult
Radiation Oncology
Other (Please specify)

Neurosurgery

Adult

Nuclear Medicine

Nuclear Medicine

Ophthalmology

Adult

Oral & Maxillofacial Services

Facio Maxillary Surgery

Orthopaedics

Adult
Other (Please specify)

Palliative Care

Palliative Care

Physicians/Internal Medicine

Clinical Haematology
General Medicine
Geriatrics
Medical Oncology
Neurology
Nephrology
Respiratory
Rheumatology
Other (Please specify)

Plastic & Reconstructive Surgery

Adults

Psychiatry

ECT
CYMH
Sub Specialty (Please specify)

Rehabilitation Medicine

Rehabilitation Medicine

Thoracic Surgery

Adult

Urology

Adult
Other (Please specify)

Vascular Surgery

Vascular Surgery

Other Clinical Practice Sought (Not applicable to Surgical Assistants)

Surgical Admitting
Medical Admitting
Consulting
Other (Please specify)

Professional Development over past 3 years - Please include any research activities, funded projects and quality assurance activity.(List below or attach CV)

Current Public Hospital Appointments (List below or attach CV)

Hospital and Appointment

Current Scope of Clinical Practice at other Private Hospitals (List below or attach CV)

Hospital and Appointment

Have you previously been refused clinical privileges at another health care facility?

Yes
No

If yes, please provide the name of the facility and rationale for refusal. Please note a senior executive of the Hospital may contact the facility.

Has your scope of clinical practice and/or appointment at any Hospital or Day Procedure Centre ever been reduced, suspended or revoked (including if done by mutual agreement) or have you had conditions attached to that appointment for any reason?

Yes
No

If yes, please give dates and particulars. Please note a senior executive of the Hospital may contact the facility

Details of all Health Care related employment within the last 10 years (List below or attach CV)

Hospital and Appointment

Special Professional Interests

Are you a member of any Specialist College(s)/Association(s)? (If yes, please provide details)

Yes
No

Publications (List below or attach CV)

Declaration and Authority

I authorise the Townsville Day Surgery, its employees, officers 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 body/organisation.

Specialist Directory

Yes
No

I authorise the Townsville Day Surgery to include my practice details in any Hospital Specialist Directory.

I authorise Townsville Day Surgery 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 Chief Executive Officer if I am convicted of a sex or violence offence or any other offence relevant to my practice as a Medical Practitioner. I authorise the Townsville Day Surgery, its officers and the Medical Advisory Committee to verify with relevant individuals, external organisations, and nominated referees the validity of all claims, including complaints made, including explicit consent for the organisation to verify my declaration regarding health status, professional registration history, claims and legal proceedings. I declare that I have no physical or mental condition or substance abuse problem that could affect my ability to exercise the scope of clinical practice requested or that would require any special assistance in order to enable me to exercise that scope of clinical practice safely and competently. I undertake to notify the Townsville Day Surgery if this statement becomes incorrect in the future. 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 declare that I am the person named in this application and that the information provided by me in this application and in connection with this application is accurate and complete and is not misleading or deceiving or likely to mislead or deceive. I understand that if I have provided misleading or deceptive information, or information which is likely to mislead or deceive, that the Townsville Day Surgery Board may (in its absolute discretion) consider that I do not have ‘current fitness’ under the Hospital By-Laws. In applying for appointment I acknowledge that I have been provided with, and read, a copy of the Hospital By-Laws and if appointed, agree to abide by the By-Laws and policies of the Townsville Day Surgery, including any annexure or variation to the By-Laws during the tenure of my appointment, all relevant legislative requirements (including compliance with HQCC Standards) and any terms and conditions which are attached to my appointment by the Board/Licensee. I understand that non-compliance with the Hospital By-Laws may be grounds for suspension, termination or imposition of conditions on my clinical privileges. I undertake to notify the Townsville Day Surgery promptly and in writing, if my scope of clinical practice is altered in any way at any other hospital or day procedure centre. I agree to attend committee and clinical meetings at the facility to support my discipline within the facility, and 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 specialty committees if required by Townsville Day Surgery. I undertake to notify Townsville Day Surgery should any information provided in this application for appointment vary in any way I acknowledge and agree to release and indemnify Townsville Day Surgery from and against all claims, including legal costs, out of a decision to suspend or terminate my accreditation or to not re-appoint me in circumstances set out in the Hospital By-Laws. In the event of myself or the aforementioned practitioner(s) being unavailable in the case of an emergency, I am agreeable to the facility seeking urgent alternative assistance with authority to be exercised only after consultation with the facility Chief Executive Officer or duly authorised person. I understand that my Appointment will be reviewed in three (3) years or earlier if considered necessary.

Name

First Last Date

Witness Name

First Last Date

Credentialing and Scope of Practice Application Form (QLD) - Renewal

Personal and Contact Information

Professional Practice Details

Professional Registration Details

Professional Indemnity

Detail the scope of Clincal Practice Requested (Not applicable to Surgical Assistants)

Other Clinical Practice Sought (Not applicable to Surgical Assistants)

Professional Development over past 3 years - Please include any research activities, funded projects and quality assurance activity.(List below or attach CV)

Current Public Hospital Appointments (List below or attach CV)

Current Scope of Clinical Practice at other Private Hospitals (List below or attach CV)

Details of all Health Care related employment within the last 10 years (List below or attach CV)

Declaration and Authority