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:
Home Phone
Preferred mailing address
PCode
Mobile Phone
PROFESSIONAL PRACTICE DETAILS PRACTICE NAME (1) BUSINESS ADDRESS:
Phone
Preferred mailing address
PCode
Facsimile
PRACTICE NAME (2) BUSINESS ADDRESS:
Phone
Preferred mailing address
PCode
Facsimile
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:
AFTER HOURS:
MOBILE PHONE: Would you be prepared to participate in an on-call roster arrangement for the Emergency Service? YES
NO
\\fileserver01\data$\CEO\CEO Files\Accreditations\Application for Accreditation Form - Medical Officers -May 31.docx
1