APPLICATION
APPLICATION FOR INITIAL APPOINTMENT AND SCOPE OF CLINICAL PRACTICE AS AN ACCREDITED PRACTITIONER
Please return your completed form with a copy of your CV, proof of registration and professional indemnity certificate and COVID-19 vaccination evidence to the CEO’s Office, St Andrew’s Hospital, karyn.verity@stand.org.au or by fax (08) 8232 5589.
PERSONAL DETAILS
TITLE: GIVEN NAMES:
SURNAME:
PREFERRED FIRST NAME:
DATE OF BIRTH:
PROVIDER NO:
EMAIL ADDRESS: PRESCRIBER NO: HOME ADDRESS: Preferred mailing address
PROFESSIONAL PRACTICE DETAILS
PRACTICE NAME (1)
BUSINESS ADDRESS: Preferred
PRACTICE NAME (2)
BUSINESS ADDRESS:
NAME OF PRACTICE MANAGER/ PERSONAL ASSISTANT:
AFTER HOURS / EMERGENCY CARE PROVISIONS
Please provide details of a registered/nominated practitioner from the same discipline who is accredited at this hospital who can be contacted for “back up” or “emergency” cover, should the Hospital be unable to contact you.
FIRST NAME: LAST NAME:
ADDRESS:
ROOMS PHONE:
MOBILE PHONE:
Would you be prepared to participate in an on-call roster arrangement for the Emergency Service?
REGISTRATION / PRACTICING CERTIFICATE
ARE YOU LICENSED TO PRACTICE MEDICINE/ DENTISTRY IN THE STATE OF SOUTH AUSTRALIA? YES / NO
Pleaseencloseacopyofyourcurrentcertificate REGISTRATION NUMBER: EXPIRY DATE:
PROFESSIONAL INDEMNITY COVER / MEDICAL DEFENCE MEMBERSHIP (LIMIT OF INDEMNITY $20,000,000)
INSURANCE COMPANY / MEDICAL INDEMNITY INSURER:
Pleaseencloseacopyofyourcurrentcertificate
POLICY NUMBER: EXPIRY DATE:
POLICY COVER/ INSURING CLAUSES:
DOES YOUR MEMBERSHIP COVER THE SCOPE OF PRACTICE APPLIED FOR? YES / NO
Pleaseencloseacopyofyourcurrentmembershipreceipt
PUBLIC LIABILITY
In accordance with the Hospital conditions I am aware of the Board’s strong recommendation to hold Public Liability Insurance to cover:
1. Damage to Hospital property
2. Damage to property in the physical and legal control of the applicant; and / or 3. Injury to Hospital employees
DO YOU MEET THE REQUIREMENTS OF YOUR COLLEGE CME ACTIVITIES? YES NO OR DO YOU PARTICIPATE IN CME ACTIVITIES?
Have your Clinical Privileges and / or appointment at any hospital or day procedure centre ever been denied, reduced, suspended or revoked or have you had conditions attached to that appointment for any reason?
YES (*If YES, give dates and particulars) NO
Have you ever been subject to an adverse finding or had conditions attached to your medical indemnity insurance policy or registration by a Medical / Dental Board (as appropriate)?
YES (*If YES, give dates and particulars) NO
Have there ever been any serious 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 Board, a Health Care Complaints Commission/Body, a Coroner, a Court or any other professional, disciplinary or similar body?
YES (*If YES, give dates and particulars) NO
Are there any unresolved complaints of which you have been formally notified?
YES (*If YES, give dates and particulars)
Have you ever had limitations or conditions applied by your insurer/ indemnifier on your existing Indemnity policy?
YES NO
(*If YES, state limitations or conditions applied) * This information is required to assess an application for scope of clinical practice and will only be used by St Andrew’s Hospital for such purposes. Information will not be disclosed otherwise.
Working with Children
Do you work with children (a child is anyone under the age of 18 years)? YES NO
*The phrase ‘work with children” is defined in the Child Safety (Prohibited Persons) Act 2016 (SA) (PP Act) as follows: “…if the person provides –
(a) a service or undertakes an activity that is child-related work in the course of their employment (b) carries on a business in the course of which an employee works with children (whether or not the person themselves works with children)”
Do you have a current WWCC or DHS/DCSI child related screening check? YES NO
Does the check confirm you are NOT PROHIBITED to work with children? YES NO If yes, have you attached a copy of your current WWCC or DHS/DCSI child related screening check YES NO
Do you declare that you will inform St Andrew’s Hospital if your working with children status changes and you are PROHIBTED from working with children? YES
UNDERGRADUATE QUALIFICATIONS:
POST GRADUATE QUALIFICATIONS:
Diplomas, Certificates, Degrees, Memberships & Fellowships
HOSPITAL APPOINTMENT(S) HELD IN THE LAST 10 YEARS:
IF FULL TIME DO YOU HAVE WRITTEN CONSENT OF THE PUBLIC HOSPITAL TO ENGAGE IN PRIVATE PRACTICE OUTSIDE OF THE HOSPITAL?
YES / NO
IfYESprovideacopyoftheapproval.
SPECIAL PROFESSIONAL INTERESTS / COLLEGE MEMBERSHIPS:
Delineation of Scope of Practice
Surgical Assistant (no admitting rights)
SPECIALIST PRACTITIONER
Anaesthetist
Adult
Cardiac – please provide evidence of TOE
Paediatrics
Pain management - please provide FPM certificate
Cardiology
Interventional Procudures
Diagnostic Procudures
EPS
Paediatric Procedures
Cardiothoracic Surgery
Dermatology
Adult
General Practitioner (no admitting rights)
Salaried Medical Officer
Emergency Department
ICU
General Surgery
Endoscopy– please provide evidence of certifcation
Colonoscopy – please provide CCRTGE certificate (plus GESA certificate if CCRTGE >3yrs old)
Upper GI – excl oesophagectomy, gastrectomy
Hepatobiliary – excl pancreatic, major liver surgery
Colorectal surgery – excl rectal cancer, complex anorectal surgery
Upper GI – including oesophagectomy, gastrectomy
Hepatobiliary – including pancreatic, major liver surgery
Paediatric Surgery
Palliative Care
Pathology Anatomical
Haematology
Clinical Chemistry
Physicians / Internal Medicine
Clinical Haematology
General Medicine
Geriatrics
Infectious Diseases
Paediatric Medical Oncology
Emergency Medicine
Adult
Paediatric
Endocrinology
Adult
Paediatric
ENT Surgery
Colorectal surgery – incl rectal cancer, complex anorectal surgery
Breast & Endocrine
Surgical Oncology
Robotic Surgery
Gynaecology
Gynaecology general
IVF
Gynaecology Oncology
Uro-gynaecology
Adult Endoscopic surgery
Paediatric
Head & Neck
Robotic
Gastroenterology
Endoscopy - please provide evidence of certification
ERCP
Colonoscopy – please provide CCRTGE certificate (plus GESA certificate if CCRTGE >3yrs old)
Advanced Endoscopic surgery (L5 and L6)
Robotic
Intensive Care
Neurosurgery
Adult Paediatric
Occupational Medicine
Ophthalmology
Adult
Paediatric
Oral & Maxillofacial surgery
Orthopaedics
Paediatric
Upper Limb
Lower Limb
Spinal
Neurology
Nephrology
Radiation Oncology
Renal Medicine
Respiratory
Rheumatology
Pain management
Plastic & Reconstructive
Surgery
Breast
Hand surgery
Facio Maxillary
General Reconstructive
Head & Neck
Skin lesions
Psychiatry
Radiology
General
Interventional
Nuclear Medicine
Rehabilitation Medicine
Urology
Adult
Paediatric
Laparoscopic surgery
Advanced Endoscopic surgery
Robotic
Vascular Surgery
SPECIAL CLINICAL SERVICES/EQUIPMENT USE YES
Advanced Laparoscopic Surgery: YES NO
Medical Practitioners performing advanced Laparoscopic surgery are required to provide details of experience, qualifications and / or education verifying their competence with the equipment and / or procedure. Please attach a copy of relevant details to this Accreditation application.
Laser Surgery:
A separate form will be sent to you for completion if you intend to perform Laser Surgery. YES NO
Da Vinci Surgery: YES NO
Requirements for obtaining scope of practice for Da Vinci surgical robot:
Medical Practitioners performing robotic surgery are required to provide details of experience, qualifications and / or education verifying their competence with the equipment and / or procedure. Please attach a copy of relevant details to this Accreditation application.
The St Andrew’s credentialing process for new robotic surgeons in all specialties (noting that Urology will have separate sub specialties for renal, cystectomy and prostatectomy);
Completed either the industry training program with Device Technology or a fellowship in robotic surgery.
Have been proctored for at least the first three cases by an experienced (completed more than 50 robotic cases) accredited robotic surgery specialist from the specific clinical specialty or sub specialty that they are seeking the scope of practice for.
That the Proctor provides a report in writing recommending that provisional accreditation be provided.
That the first five independent robotic cases performed by the surgeon will be reviewed to determine whether Full accreditation as a robotic surgeon will be provided.
That a quarterly review of all robotic surgical procedures will be conducted to ensure satisfactory clinical outcomes and sufficient volume of cases are performed. This review will be considered by the Credentials committee.
SERVICE DESCRIPTION: Describe the intended services to be provided:
SPECIFIED ADDITIONAL UNDERTAKINGS: Describe any additional undertakings:
SPECIFIED EXCLUSIONS: Please identify any specific exclusions
REFERENCES: Please provide details or three (3) Referees appropriate to your specialty and area of practice and who can attest to your recent practice and who are not related to you. Please note you must nominate at least one (1) referee who currently has accreditation with the hospital. SPECIALTY: