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
*
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
Home Address
- Same as Mailing Address
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Phone Number*
Mobile Phone
Other Phone Numbers
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)*
- Specialist Medical Practitioner
- General Medical Practitioner
- Pharmacist
- Locum Tenens
- Dental Practitioner
- Surgical Assist (no admit rights)
- Allied Health Professional
- Employed Medical Officer
- Nurse Practitioner
- Registered Nurse (employed by VMO)
- Registered Nurse working in specialised area
Priveleges Sought*
- Admitting
- Consulting
- Surgical Assist
- Anaesthetic
- Sedation (GP Only)
- Surgical
- Surgical (RN Only)
- Procedural
- Allied Health
- Nursing Assessment & Patient Education
- Contract of Employment (Employed Medical Officers)
- Contract of Employment (Employed Allied Health Professional)
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 CPD certificate)
Attached CPD Certificate*
List Professional Development*
Current Public Hospital Appointments (List below or attach CV)
Hospital and Appointment
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.
Attach Your CV*
Drop files here or
Please attached a copy of your CV below.
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/interstate travel or had contact with a suspected or confirmed case of coronavirus (COVID-19) in the last 14 days.
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.

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 CPD certificate)

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