PHO_provider_application_(Jan_22)_Fillable_PDF

CONFIDENTIAL 27 January 2022

APPLICATION FOR “PROVIDER” MEMBERSHIP TO THE WBOP PHO Type of Membership    

If Contracted Locum, please state your host doctors NZ Medical Council Number 1 for pharmaceutical & laboratory prescribing

Nurse / Nurse Practitioner General Practitioner Practice Owner Contracted Locum (over 6 months service)  

Subcontractor Employed by Practice

Host Doctor’s Council number ________________ Host Doctor __________________________________ DOB:

Full Name

Full Time Equivalent (FTE) Hours:

Start Date Practice Name Are you working at anywhere else?  Yes Eg. Hospital Private Contact Phone/ Cell Number:

 No

NZ Medical Council Registration No.

If YES, what are the average hours per week?

Email address

NZ Nursing Council Registration No. Date of acceptance in New Zealand

Provider requires access to the following WBOP PHO clinical tools:

Health Practitioner Index No.

 Thalamus

 Halcyon

Police Check date Current Annual Practicing Certificate:

No

Yes

Please attach a copy of this certificate by email QUALIFICATIONS HELD

Qualifications

1st Qualification to Practise Medicine/Nursing Other qualifications

Current Indemnity Insurance:

 Yes

No

Insurance Value $ ....................

1

If another prescribing process is preferred, please discuss this with the PHO

Date

CONFIDENTIAL 27 January 2022

Have you had a complaint made about you in the past three years to a medical disciplinary body? If YES please given details on a separate page.

Do you have any complaints to a medical disciplinary body pending? If YES please give details on a separate page.

Yes

 No

Yes

No

 Yes

Are you a member of the RNZCGP? If YES, Please Tick One

 

 No

Associate (2) Member Fellow

Year of Award: Are you included on the vocational register of general practice?

Are you a member of a peer review group?

(2)

If an Associate Member then, are you currently on the GPEP Training

Yes

No

Yes

No

Yes

No

Programme?

When is your expected completion date?

DECLARATION 1. I hereby certify that, to the best of my knowledge, the above information is accurate and complete.

2.

I understand that once contracted to the PHO, I must notify the PHO within 10 days (or sooner if possible) of any changes to the information provided on this form, except information relating to the loss of my registration, which must be reported to the PHO within 24 hours.

3.

I authorise the PHO to disclose the information contained in this Application Form to the Clinical Directorate and the Network Clinical Policy Committee for the purposes of reviewing my eligibility to join the PHO network and I consent to such parties receiving this information.

4.

I authorise the PHO to disclose such information from this Application Form to the DHB as prescribed in the Agreement between the PHO and DHB for the purposes of reviewing my eligibility to provide the health services.

5.

I understand my obligations under the Privacy Act 1993 as a member of the PHO.

6.

I understand that my email address will be added to the mailing list for PHO related updates, and that my email address will not be shared outside the organisation. I am aware that I can unsubscribe at any time.

Signed:

Date:

Witness:

Date:

Signed by Practice Nominee:

Date:

Witness:

Date:

Save Form

Clear Form

Submit Form to PHO

-------------------------------------------------------------------------------------------------------------------------------------------------------------WBOP PHO Office Use Only Contract Direct to Practice To Network Administrator Tick to confirm: Staff details have been sent to nsadmin@wboppho.org.nz to be added to relevant mailing lists.