Application for AP Accreditation/Credentialing
Referee's Report
Referee Name:
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Applicant Name
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Clinical Privileges Requested:
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I am currently an accredited medical practitioner at Ramsay Surgical Centre Charlestown
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Yes
No
is YES, please indicate which Ramsay Health Care Hospital
I have a financial / business relationship with the applicant
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Yes
No
What is your relationship with the applicant?
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How long have you known the applicant?
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Please provide comments on the applicants:
Training:
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Recent Experience:
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Competence:
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Clinical Judgement:
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Current Fitness to Practice:
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Good Character:
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Professional Capability and Knowledge:
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Communication skills with Patients:
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Communication skills with Medical Practitioners including GP's:
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Communication skills with Other health practitioners, including nursing staff:
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General clinical skills including appropriate referrals practice and insight into scope of practice and capabilities, clinical judgement, provision of after hours cover:
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Specific specialty skills including, as appropriate, procedural skills:
Specialty / Skills:
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Specific procedure / skills:
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Would you be happy to have this Doctor working in your practice as a Colleague?
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Yes
No
I Confirm that I am not personally related to the applicant
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Yes
No
Contact Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Date
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-
Month
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Day
Year
Date
Signature
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Please verify that you are human
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Submit
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