Renewal Application Form – Townsville Day Surgery

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

Application for appointment and scope of clinical practice as an accredited practitioner

Personal and Contact Information
Name*
Given Names Surname
Preferred Title*
Prefix
(e.g. Dr, Mr, A/Prof; Prof)
Preferred Name
Any former names including maiden name
Date of Birth*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address
- Same as Home Address
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Phone Number*
Mobile Phone
Other Phone Numbers
Home Phone Fax
Email Address*
Personal Business
Emergency Contact*
Name Relationship Mobile Phone Email
Other Phone Numbers
Home Phone Work Phone
*
Provider Number Prescriber Number
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, who has agreed to deputise for you. The Medical Practitioner must be available for contact by the Hospital in the case of an emergency if you are unavailable.*
Name Specialty Contact Number
Clinical Practice sought in the following category(s)*
- Specialist Medical Practitioner
- General Medical Practitioner
- Pharmacist
- Locum Tenens
- Dental Practitioner
- Surgical Assist (no admit rights)
Priveleges Sought*
- Admitting
- Consulting
- Surgical Assist
- Anaesthetic
- Sedation (GP Only)
- Surgical
- Procedural
Detail the scope of Clincal Practice Requested (Not applicable to Surgical Assistants)
Anaesthesia
- Adults
- Other (please specify)
Cardiac Surgery
- Adult
Dental
- Oral & Maxillofacial
Dermatology
- Adult
Endocrinology
- Adult
Gastroenterology
- Endoscopy
- Other (please specify)
General Surgery
- Adult
- Endoscopy
- Laparoscopic
- Colorectal
- Other (Please specify)
Gynaecology
- Gynaecology General
- Uro-gynaecology
- Ultrasound
- Advanced Endoscopic
- Laparoscopic
- IVF
- Other (Please specify)
Medical Imaging
- Adult
Ophthalmology
- Adult
- Other (Please specify)
Orthopaedics
- Adult
- Other (Please specify)
Pain Management
- Adults
- Other (Please specify)
Plastic & Reconstructive Surgery
- Adults
- Other (Please specify)
Urology
- Adult
- Other (Please specify)
Vascular Surgery
- Adult
- Other (Please specify)
Other Clinical Practice Sought (Not applicable to Surgical Assistants)
Field
- 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. (Please list below or attach CV at the end of this form)
List Professional Development*
Current Public Hospital Appointments
(Please list below or attach CV at the end of this form)
Please list Hospital Name & Appointment/s below
Current Scope of Clinical Practice at other Private Hospitals
(Please list below or attach CV at the end of this form)
Please list Hospital Name & Appointment/s below*
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
(Please list below or attach CV at the end of this form)
Please list Hospital Name & Appointment/s below*
Special Professional Interests
Are you a member of any Specialist College(s)/Association(s)?*
- Yes
- No
If yes, please provide details
Publications

(Please list below or attach CV at the end of this form)
NOTE - COPIES OF THE FOLLOWING MUST ACCOMPANY THIS APPLICATION
Please upload required documents below:
Current CV*
Registration Certificate
Indemnity Insurance
Covid Vaccination Statement*
Immunisation History Statement*
Post Graduate Qualifications and copy of College Fellowship (if applicable)
Copy of certificates showing participation in continuing medical education
Additional Documents, Certificates or Statements
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

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COVID-19 UPDATE: Please notify us immediately if you have recently returned from overseas travel in the past 7 days or had contact with a suspected or confirmed case of (COVID-19).
Please DO NOT enter the Townsville Day Surgery premises if you are unwell, have a temperature, cough or cold. Where possible, pre-admission forms can be completed online via the “pre-admit” link. Masks are Mandatory in this facility.

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

Current Public Hospital Appointments

Current Scope of Clinical Practice at other Private Hospitals

Details of all Health Care related employment within the last 10 years

NOTE - COPIES OF THE FOLLOWING MUST ACCOMPANY THIS APPLICATION

Declaration and Authority