PresMed Australia - Re-Accreditation Form

PresMed Australia - Clinician Re-Accreditation form

Application for Appointment as an Accredited Practitioner - Re-Accreditation

Facility/Facilites of Re-Accreditation

Application for Appointment as an Accredited Practitioner - Re-Accreditation
Please select the PresMed Australia facility/facilities you will be applying for re-accreditation at:*

Chatswood Private HospitalCentral Coast Day HospitalCanberra MicrosurgeryDevonport Eye HospitalEpping Surgery CentreMadison Day SurgeryMetWest Surgical

Specialty*
Scope of Practice (CV + Insurance Indemnity upload)

Specify areas of clinical practice applied. CV to include specialty and sub-specialty qualifications and experience.
CV Upload*

Please upload your CV here.
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Insurance Indemnity Upload*

Please upload your Insurance Indemnity here.
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(Anaesthetists Only) Anaesthetists electing to be accredited for paediatrics must nominate the age range/s below, qualifications/experience in paediatric anaesthesia and the frequency of paediatric lists at a hospital providing children’s services:

3 months to 1 year1 year to 2 years2 years to 8 years8 years to 14 years
(Anaesthetists Only) Please advise which Surgeon/s you will be working with:

Personal Details
Title:*

DrProfA/ProfMrMrsOther
Given Name*
Surname*
Any former name including maiden name:
Prescriber Number*
Provider Number(s): Please specify your provider number for each facility you are applying for re-accreditation at:*
Date of Birth*

DayMonthYear
Date
Language(s) Spoken*
Residential Address*
Residential Postcode*
Personal Telephone
Facsimile (Fax)
Mobile No.*
Personal Email Address*
Practice Address*
Practice Postcode*
Practice Telephone*
Practice Facsimile (Fax)
Practice Email Address*

Registration and Personal Development
Please supply your current AHPRA registration number here:*
Please supply your specialty as detailed on your current registration with AHPRA:*
Please provide details (e.g. courses attended relevant to your appointment) of your compliance with the Continuing Education/Professional Development/Recertification or Maintenance of Standards Program of your College.*
Current AHPRA Registration + Continued Medical Education Certificate Upload

Please upload a copy of your current registration with AHPRA and any certificate(s) that display participation in Continued Medical Education here.
AHPRA Registration upload*

Please upload your AHPRA Registration here.
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Continued Medical Education Certificate Upload*

Please upload any certificate(s) that display participation in Continued Medical Education here.
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Nomination Alternative in Event of Emergency (if changed)

In the event that I am unable to be contacted for a clinical emergency, the person nominated below is an appropriately qualified Accredited Practitioner, at the facility in which I am applying for accreditation, who has agreed to deputise for me (please only fill in if the nominated person has changed):
Name of nominated person:
Nominated person's contact phone numbers:

Confirmation Form

I confirm that the information contained in this document is true and accurate 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 Board of the PMA Facility/Facilities at which I am applying to be accredited/accredited may (in its absolute discretion) consider that I do not have “Current Fitness” under the PMA By-Laws. I agree that I will notify the CEO of the PMA Facility/Facilities at which I am accredited of any material changes to the information provided by me in connection with this application as soon as possible after the change. I understand that my Appointment as an Accredited Practitioner if granted will be reviewed at the end of the current quinquennium or earlier if considered necessary.
If appointed, I agree to abide by the PMA By-Laws and policies of the facility at which I am accredited.
Name*

First NameLast Name
Signature*

Clear
Signature Date*

DayMonthYear
Date
Witness Name

First NameLast Name
Witness Signature

Clear
Witness Signature Date

DayMonthYear
Date

Clinical Education Compliance Form
Name*

PrefixFirst NameLast Name
The following educational topics are mandatory training requirements under the National Safety and Quality Standards for all clinical workforce in Australian Hospitals. This includes Accredited Medical Practitioners (AMP).

As part of the facilities Application for Accreditation process, the following self-directed learning educational information is provided on our website at https://www.presmed.com.au/our-doctors/ comprising:
- Emergency Procedures:
  Emergency Codes
  Emergency Response Assessment
  Malignant Hyperthermia
  Evacuation
  Power Failure
  Cardio Pulmonary Resuscitation
- Aseptic Technique:
  Hand Hygiene
- Open Disclosure
- Complaints
- Patient Centred Care
- Antimicrobial Utilisation
In addition to the Hospital’s Board & Medical Advisory & Audit Committee endorsed:
- Patient Selection Protocol
- Approved Adult Procedures Policy
- Approved Paediatric Procedures Policy
- Approved Fasting and Medication Protocol
I have read and understand the AMP Education Pack*

YesNo
I have read and understand the Approved Procedures and Patient Selection Protocol:*

YesNo
Signature*

Clear
Date of Signature*

DayMonthYear
Date
Should be Empty:

PresMed Australia - Clinician Re-Accreditation form