Credentialing & Scope of Practice Application & Renewal Form – Visiting Medical Practitioners

Application Type

Application Type*

New Application

Renewal Application

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 Person

Emergency Contact*

Name Relationship Mobile Phone Email

Other Phone Numbers

Home Phone Work Phone

Name of Partner/Spouse*

(for Hospital invitation list)

Provider Details

Provider Number Prescriber Number

Identification Check (New Applicants Only)

100 POINTS OF IDENTIFICATION REQUIRED - (Please upload copies of the following to ensure you meet the 100 points of identification)

Drivers Licence (60 Points)

Max. file size: 512 MB.

Birth Certificate (50 Points)

Max. file size: 512 MB.

Passport (50 Points)

Max. file size: 512 MB.

Medicare Card (40 Points)

Max. file size: 512 MB.

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*

Max. file size: 512 MB.

Registration Details*

Registration Number Category of Registration Expiry Date

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

Yes

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

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*

Max. file size: 512 MB.

Indemnity Insurance*

Indemnity Insurance Number Category of Coverage Insurer Name Expiry Date

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

Yes

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

If yes, please provide details

Are there any current claims against you with your insurer, Medical Board (or other Registration Board) or Office of the Health Ombudsman (OHO)?*

Yes

If yes, please provide details

Medico Legal*

* 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.

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 OHO, 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

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

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?

Immunisation History Check – Townsville Day Surgery requires each new applicant to provide a copy of their Immunisation History Statement (or alternatively Serology results).

Max. file size: 512 MB.

(Please attach copy of your Immunisation History Statement)

In Case of Emergency - Deputy Medical Officer

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.

Deputy Medical Officer*

Name of Accredited Nominee Specialty Contact Number (Mobile)

Clinical Practice sought in the following category(s)*

Specialist Medical Practitioner

General Medical Practitioner

Fellow Medical Practitioner

Locum Tenens

Dental Practitioner

Surgical Assist (no admit rights)

Priveleges Sought*

Admitting

Consulting

Surgical Assist

Anaesthetic

Sedation (GP)

Surgical

Procedural

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

Anaesthesia

Sedation Only

Other (please specify)

Anaesthesia (Other)

Dental

Dental Assistant

Dental

Dental Practitioner

Gastroenterology

Endoscopy

Other

Gastroenterology (Other)

General Surgery

Endoscopy

Laparoscopic

Colorectal

Other (Please specify)

General Surgery (Other)

Gynaecology

Gynaecology General

Uro-gynaecology

Ultrasound

Advanced Endoscopic

Laparoscopic

IVF

Other (Please specify)

Gynaecology (Other)

Medical Imaging

Endoscopy

Other (please specify)

Medical Imaging (Other)

Ophthalmology

Other (please specify)

Ophthalmology (Other)

Orthopaedics

Other (please specify)

Orthopaedics (Other)

Pain Management

Other (please specify)

Pain Management (Other)

Plastic & Reconstructive Surgery

Other (please specify)

Plastic & Reconstructive Surgery (Other)

Registered Nurse

Supporting Personnel

IVF Scientist

Medical Scribe

Other (please specify)

Supporting Personnel (Other)

Surgical Assistant

Urology

Other (Please specify)

Urology (Other)

Vascular

Other (please specify)

Vascular (other)

Other Clinical Practice Sought (Not applicable to Surgical Assistants)

Other Clinical Pactice

Surgical Admitting

Medical Admitting

Consulting

Other (Please specify)

Clinical Field (Other)

Referees

For each major specialty in which you are seeking clinical practice, please provide names, addresses, telephone numbers, facsimile numbers and email addresses of three (3) professional referees (at least one from your own profession) who can attest to your recent practice and have known you for at least 12 months within the past 3 years. We prefer (where possible) that these referees are independent. However, where there is a relationship which may lead to a bias, such as a referee and the applicant are in business together as a partnership, or are employer/employee, then this relationship must be disclosed by you to the hospital. Please note that your referees will be contacted and asked to provide a written reference.

Referee 1 Name*

First Last

Address*

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

Phone*

Facsimile

Email*

Referee 2 Name*

First Last

Address*

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

Phone*

Facsimile

Email*

Referee 3 Name*

First Last

Address*

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

Phone*

Facsimile

Email*

Primary Undergraduate Qualification

(Please list below or attach CV at the end of this form)

Please list Name of University/Institution, Degree/s, Graduation Year/s*

List one qualification per line

Postgraduate Qualifications, Degrees, Diplomas, College or Professional Qualifications

(Please list below or attach CV and copies of qualification/s at the end of this form)

Please list Qualification, Date Obtained and Accredited Training Organisation

List one qualification per line

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 one qualification per line

Current Public Hospital Appointments

(Please list below or attach CV at the end of this form)

Please list Hospital Name & Appointment/s below

List one per line

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/s & Appointment/s below*

List one qualification per line

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

Yes

If yes, please provide the name of the facility and rationale for refusal. Please note a Hospital Management member 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

If yes, please give dates and particulars. Please note a Hospital Management member may contact the facility.

Have you ever been disciplined, undergone or been required to take (remedial or otherwise) a program, course or therapy for workforce, professional or personal behaviour related to your practice, or to your credentials at a health facility?*

Yes

If yes, please give dates and particulars. Please note a Hospital Management member 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/s & Appointment/s below*

List one per line

Special Professional Interests

List one per line

Are you a member of any Specialist College(s)/Association(s)?*

Yes

If yes, please provide details

List one per line

Publications

Please list one per line below or attach CV at the end of this form

NOTE - COPIES OF THE FOLLOWING MUST ACCOMPANY THIS APPLICATION

Please upload required documents below. If you have already upload the file listed in the above sections of this form, please disregard that line.

Current CV

Max. file size: 512 MB.

Proof of Identity Documents

Max. file size: 512 MB.

Registration Certificate

Max. file size: 512 MB.

Indemnity Insurance

Max. file size: 512 MB.

Covid Vaccination Statement

Max. file size: 512 MB.

(if applicable)

Immunisation History Statement

Max. file size: 512 MB.

Post Graduate Qualifications and copy of College Fellowship

Max. file size: 512 MB.

(if applicable)

Most recent CPD Certificate from your College

Max. file size: 512 MB.

Executed copy of the Clinicians Code of Conduct

Max. file size: 512 MB.

(if applicable)

Copy of Hand Hygiene Certificate

Max. file size: 512 MB.

Hand Hygiene: https://nhhi.southrock.com/cgi-bin-secure/Home.cgi

(Certificate from another hospital or education program acceptable)

Additional Documents, Certificates or Statements

Max. file size: 512 MB.

Declaration and Authority

I authorise the Townsville Day Surgery to release my contact details, including mobile phone number, to other VMO’s that currently hold clinical privileges at Townsville Day Surgery:*

Yes

I authorise Townsville Day Surgery Pty Ltd (‘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.
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 Facility Manager or duly authorised person if I am convicted of a sex or violence offence or any other offence relevant to my practice as a Medical Practitioner.
I authorise 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 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 Medical Practitioners By-Laws.
I declare that my personal immunisation status is current for preventable diseases. I declare that I will continue to maintain the appropriate immunisation status for the duration of my clinical privileges.
In applying for appointment I acknowledge that I have been provided with, and read, a copy of the Medical Practitioners By-Laws and if appointed, agree to abide by the Medical Practitioners By-Laws and policies of the Townsville Day Surgery, including any annexure or variation to the Medical Practitioners By-Laws during the tenure of my appointment, all relevant legislative requirements (including compliance with Health Ombudsman Standards) and any terms and conditions which are attached to my appointment by the Board/Licensee. I understand that non-compliance with the Medical Practitioners By-Laws may be grounds for suspension, termination or imposition of conditions on my clinical privileges.
I undertake to notify 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 Medical Practitioners 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 Manager 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