Dear Doctor APPLICATION FOR ACCREDITATION / CLINICAL PRIVILEGES When applying for Clinical Privileges at Maitland Private Hospital, the following documentation must be provided before your application can be approved. □ Application for Accreditation form (enclosed) □ Evidence of current APHRA registration □ Evidence of current Professional Indemnity Insurance (Certificate of Currency)

showing the following: (a) amount insured for (b) date insured to (c) scope of practice/category insured for, eg Orthopaedics

□ Current CV □ Certified copy of medical degree and specialist qualifications □ EPA Radiation license and/or laser certification (if scope of practice encompasses

fluoroscopy/laser/angiography equipment) □ Copy of certificate showing participation in Continuing Medical Education (where

appropriate) □ Name, address and phone number of three (3) referees, two (2) of which should be

from the same specialty. □ Certified copy of two (2) forms of photo identification (drivers license & passport) □ Evidence of Current Working With Children Check (new system from June 2013) □ Completion of Consent form(s) (enclosed) Please forward the above documentation to the Executive Assistant prior to your commencement at Maitland Private Hospital. Please send to 175 Chisholm Road East Maitland NSW 2323, fax (02) 4933 8883 or via email jacqueline.sharkey@healthecare.com.au, at your earliest convenience. Yours sincerely

SUE-ELLEN BLOMFIELD Acting Chief Executive Officer

Healthe Care Australia Pty Ltd Hospital By-Laws Jul-16

Page 1 of 11

ANNEXURE A1 APPLICATION FOR ACCREDITATION – MEDICA L PRACTITIONER OR DENTIST (INCLUDING SURGICAL ASSISTANT - MEDICAL) AT MAITLAND PRIVATE HOSPITAL

Application for Accreditation as a Medical Practiti oner (including Surgical Assistant – Medical) or Dentist

Please submit your completed application form with the documentation requested in the sections following to the Chief Executive Officer at Maitland Private Hospital

� New Appointment � Reappointment

For Reappointment:

If this is an application for reappointment and there are no changes to the information required in this application you will only be required to tick the box below, sign and complete your contact details on this application.

� This is an application for my reappointment and there are no changes to the information required in the Application for Accreditation since I last applied at Maitland Private Hospital.

Signature of Medical Practitioner Date

IF YOU WOULD LIKE TO APPLY FOR ACCREDITATION AT ANY OTHER NEW SOUTH WALES FACILITIES, PLEASE INDICATE BELOW

� Brisbane Waters Private Hospital � Dubbo Private Hospital � Gosford Private Hospital

� Hurstville Private Hospital � Lingard Private Hospital � Maitland Private Hospital

� Mayo Private Hospital � Toronto Private Hospital

Section 1: Personal Details

Title: (A/Prof, Dr, Mr, Prof)

Surname of Applicant:

First Names in full:

Any Former Name Including Maiden Name:

Date of birth:

Accreditation category: (Please refer to page 3 for the criteria category)

Partner / Spouse Full Name: (optional - for invitation purposes only)

Provider Number:

Prescriber Number:

Emergency Contact Name:

Emergency Contact Number:

Healthe Care Australia Pty Ltd Hospital By-Laws Jul-16

Page 2 of 11

Personal Address Details Please tick � your preferred mailing address that is Personal or Practice or Other:

� Residential Address:

Suburb: Post Code:

Home Phone Number: Home Facsimile:

Mobile Number:

Email:

Practice Address Details (primary): � Practice Address

Suburb: Post Code:

Practice Telephone: Practice Facsimile:

Pager Telephone: Pager Number:

Mobile Number:

Email Address:

Other Address (other consulting rooms etc):

� Other Address

Section 2 Qualifications ( Please attach your Curriculum Vitae and Qualification Documents)

Undergraduate qualifications, university and year o f graduation:

Year Obtained: Qualification: Institution:

Postgraduate qualifications, degrees, diplomas, fel lowship: Note: Certified copies of original qualifications should be obtained, if possible

Year obtained: Qualification: Authorising Body:

Special comments on post graduate experience:

Healthe Care Australia Pty Ltd Hospital By-Laws Jul-16

Page 3 of 11

Year obtained: Qualification: Authorising Body:

Special comments on post graduate experience:

Year obtained: Qualification: Au thorising Body:

Special comments on post graduate experience:

Section 3 Appointments:

Current Appointments:

Dates: Facility: Appointments:

Previous Appointments (last ten years):

Dates (From / To): Facility: Appointments:

Itemise Postgraduate Educational Activity in the pa st three years:

�

�

�

�

Nature of current practice and place of work

Healthe Care Australia Pty Ltd Hospital By-Laws Jul-16

Page 4 of 11

Publications (Please attach list or CV): Attached? Yes � No �

Membership of colleges and/or other relevant Associ ations (Please attach list or CV):

Yes � No �

Section 4 Accreditation, Scope of Practice

Accreditation is sought in the following categories :

� Career / Contracted Medical Officer

� Consultant Emeritus (No admitting rights)

� Consultant Specialist/General Practitioner

(No admitting rights)

� Dental Specialist

� Dentist

� General Practitioner

� Employed Medical Officer

(Resident, Registrar, Career Medical Officer)

� Specialist Practitioner

� Staff Specialist

� Surgical Assistant (No admitting rights)

Accreditation is sought to:

� Admit

� Consult

� Diagnostic / Treat

� Assist

Specialty In Which Accreditation Is Applied For:

P

Please complete Scope of Practice (page 3) to complete your Specialty (n/a Surgical Assistants)

Does your scope of practice require the use of:

1) Fluoroscopy / Laser and / or Angiography Equipment � Yes � No If Yes attach the EPA Radiation Licence to this application and

note the Radiation User Licence Expiry Date�

Expiry:

2) Laser Equipment � Yes � No

If Yes attach the Laser Certification to this application and note

the Laser Certificate Expiry Date�

Expiry:

Appointment Period (to be completed by the hospital )

� Temporary � Quinqennium � Other Term ------ / ----- / 20-- to 30 / 06 / 2017

Healthe Care Australia Pty Ltd Hospital By-Laws Jul-16

Page 5 of 11

Surgical Assistant applicants only: Name of accredited practitioner at each applicable hospital who will provide a reference for you (minimum 3):

Name Address & Phone Number Hospital

Name Address & Phone Hospital

Name Address & Phone Hospital

Name Address & Phone Hospital

Name Address & Phone Hospital

Accreditation (Please tick):

� Permanent

� Temporary

from _______/______/ 20____ to _______/______/ 20____

Healthe Care Australia Pty Ltd Hospital By-Laws Jul-16

Page 6 of 11

Clinical privileges are sought in the field(s) of: (Not applicable to Surgical Assistants) � Anaesthesia � Adults � Cardiac-Adult Only � Neonatal (<1 year old) � Obstetrics � Paediatrics (>1 year old) � Trans-oesophageal

Echocardiography (TOE)-Adults Only � Chronic Pain

� Cardiac Perfusion

� Cardiology � Cardiologists � TOE � Procedural Cardiologist � Diagnostic Angiography � Interventional Cardiologist � Angioplasty � Electro Physiologist

� Emergency Medicine

� Gastroenterology � Diagnostic Upper

Gastrointestinal Endoscopy � Therapeutic Upper

Gastrointestinal Endoscopy � Sclerotherapy � Oesophageal Banding &

Placement of Prostheses � Oesophageal Dilatation � Flexible Sigmoidoscopy � Diagnostic Colonoscopy � Endoscopic Retrograde

Cholangiopancreatography (ERCP) & associated Therapeutic Interventions � Biliary Stenting � Percutaneous Gastrostomy

(PEG)

� Gynaecology-General � Advanced Endoscopic

Surgery � Gynaecology General � Laparoscopic Surgery � Prolapse Surgery � Ultrasound � Assisted Reproductive

Services � Gynaecological Oncology � Gynaecology Oncology � Uro-Gynaecology

� Intensive Care � Adult � Paediatric

Medicine � General Medicine � Adult � Paediatric Medicine � General Medicine � Neonatology (34 weeks or later) � Medical Oncology � Dermatology � Endocrinology � Geriatrics � Hepatology � Immunology � Infectious Diseases � Internal Medicine � Neurology � Oncology � Adult � Medical Oncology � Paediatric Oncology � Radiation Oncology � Palliative Care � Haematology � Rehabilitation � Renal Medicine � Nephrology-General � Nephrology-Interventional � Renal Dialysis � Respiratory Medicine � Bronchoscopy-Diagnostic � Bronchoscopy-Therapeutic � Sleep Medicine � Rheumatology � Other please specify:

� Obstetrics � Maternal Fetal Medicine � Ultrasound � Uro-gynaecology

� Nuclear Medicine

� Occupational Medicine

� Pathology

� Psychiatry � General Adult � Consultation - Liaison � Addiction Psychology � PTSD (EMDR) � ECT � TMS � Eating Disorder

� Psychotherapy

� Radiology � Diagnostic Imaging � Interventional Radiology � Cardiac Catheterisation � Diagnostic (perform at

least 100 procedures per annum) � Interventional (perform

at least 75 procedures per annum) � Vascular Catheterisation � Diagnostic � Interventional

Surgery � Cardiothoracic Surgery � Adult Only � Valvular Procedures � Coronary Artery Bypass

� Off Pump Procedures � Minimally Invasive

Surgery � Arrhythmia Surgery � Thoracic Aorta

Procedures � Thoracic Lung

Procedures � Insertion of Pacemaker � Paediatric Only

� Other please specify:

� Dental � Adult � Paediatric

� Dental Specialist � Specify:

� ENT Surgery � Adult � Paediatric � Paediatric Endoscopic � Adenoidectomy � Bronchial Procedures � Ear Procedures � Facial Nerve � Laryngeal Procedures � Otolaryngeal-Head& Neck � Pharyngeal Procedures � Tonsillectomy � Tracheal Procedures � Other please specify:

Healthe Care Australia Pty Ltd Hospital By-Laws Jul-16

Page 7 of 11

� General Surgery � Adult � Colorectal Surgery � Endocrine Surgery � Adrenalectomy � Thyroidectomy � Endoscopic Surgery � Gastrointestinal Surgery � Laparoscopic Surgery � Diagnostic � Interventional � Upper GI Surgery

� General Surgery – sub specialty � Paediatric � Breast Surgery � Oncoplastic � Hepatobiliary & Pancreatic

Surgery � Oesophagectomy � Bariatric – Adults & (16-

18yo) only � Lap Banding � Modified Roux-en-Y � Sleeve Gastrectomy

� Neurosurgery � Adult � Paediatric � Nerve Procedures � Spinal Procedures � Cranial Procedures

� Ophthalmology � Adult � Paediatric � Cataract Surgery � Corneal transplantation � Eyelid Surgery � Glaucoma Surgery � Lacrimal Surgery � Oculoplastic � Orbital Surgery � Pterygium Surgery � Refractive Surgery � Squint Surgery

� Oral and Maxillofacial Surgery � Adult � Paediatric � Facio-Maxillary Surgery � Mandibular Osteotomy � Other please specify:

� Orthopaedics - General � Adult

� Paediatric � Arthroscopy � Fracture Management � Major Joint Replacement � Podiatric Surgery

� Orthopaedics – sub specialty � Reconstructive Surgery � Spinal Surgery

� Paediatric Surgery � Other please specify:

� Plastic and Reconstructive Surgery � Adult � Cosmetic Surgery � Augmentation Mammoplasty � Abdominoplasty � Blepharoplasty � Body Contouring � Body Lift � Brachioplasty � Brow Lift � Laser Ablation � Liposuction � Mastopexy � Mentoplasty � Otoplasty � Rhinoplasty � Rhytidectomy � Reconstructive Surgery � Breast reconstructive surgery � Burns Surgery � Facial Reconstruction � Hand Surgery � Microsurgery � Neurovascular Flaps � Surgery for congenital deformity � Paediatric � Bats Ears Only � Repair Lacerations Only � Revision of Scars Only � Other please specify

� Urology - General � Adult � Paediatric � Endoscopic Urology

� Laparoscopic Urology � Laser � Green Light Laser � Open Urological

Procedures � Other please specify

� Urology – Sub Specialty � HiFU � Lithotripsy

� Vascular Surgery � Procedure: � Anastomosis � Arterial Patch � Bypass � Decompression � Enbolectomy � Endarterectomy � Ligation of Aneurysms � Repair � Replacement � Thrombectomy � Vascular Trauma of the

following: � Adnominal � Aortic � Mesenteric � Open � Axillary, Subclavian � Carotid Surgery – Open � Endovascular Procedures � AAA Stent Grafts � Diagnostic Procedures � Embolisation Procedures � Peripheral Interventions � Renal Stenting � Femoral � Lilac � Jugular � Renal � Temporal � Thoracic

Page 8 of 11

Other privileges sought: (Not applicable to surgical assistants) Field Surgical Admitting Medical Admitting Consulting Other (specify)

Section 5 Referees For each speciality in which you are seeking privil eges, please provide the names, addresses and contact numbers of three peer referees in Australia who can attest to your recent practice and who are not related to you nor financially linked with or f inancially dependent on you. (Not applicable to surgical assistants)

Name of Referee 1:

Specialty:

Address:

Contact Number: Email:

Name of Referee 2:

Specialty:

Address:

Contact Number: Email:

Name of Referee 3:

Specialty:

Address:

Contact Number: Email:

Section 6 Registration Please record your current AHPRA registration numbe r and attach a photocopy of your registration certificate to the application:

State(s): Registration Number: Expiry Date:

Scope of Clinical Practice:

6.1 Do you have any endorsements or notations against your current medical registration? (circle)

Yes � No �

If Yes provide details:

Healthe Care Australia Pty Ltd Hospital By-Laws Mar-16

Page 9 of 11

6.2 Do you have any conditions, undertakings or reprimands against your current medical registration? (circle)

Yes � No �

If Yes, provide details:

6.3 As per Healthe Care Australia’s Hospital By-Laws should AHPRA impose any conditions and/or restrictions on my medical registration or should I enter into an agreement with AHPRA about these matters, in the future, I confirm that I will immediately notify the Hospital’s CEO of the nature and extent of such conditions and/or restrictions.

Yes � No �

Section 7 Insurance and Disclosure

Please state the name of your Medical Defence Organisation or your Professional Indemnity Insurance Provider and attach a copy of your current Professional Indemnity Insurance Certificate and Schedule to this application.

NB: Accredited Practitioners must hold professional indemnity insurance cover issued by an Australian insurer. All Accredited Practitioners must hold a minimum level of cover of $20 million for each claim and in the aggregate.

Where the Accredited Practitioner will be conducting Clinical Trials or Research this needs to be noted on the policy.

Please note it is a requirement to provide a copy yearly upon policy renewal to the Hospital CEO as documentary evidence of the level of this cover and also to immediately advise any material changes to the level of cover or conditions of the policy.

Name on Policy: Expiry Date: / /20

Policy Number: Insurance Company:

Category of cover: (insert specialty e.g. Surgeon – General):

Billing less than $ (insert amount) (insert specialty)

7.1. Does your insurance fully cover the types of privileges you have applied for? Yes � No �

7.2. Do you have any conditions imposed by your indemnity insurance provider that you are required to comply with in order to maintain coverage or are there limitations on coverage ? (If so, please provide a copy of the relevant section of your insurance policy)

Yes � No �

7.3. I consent to Healthe Care Australia contacting my indemnity insurance provider directly, should it desire for any reason, to obtain a full copy of my indemnity insurance policy. (If yes, please provide the attached signed authority)

Yes � No �

7.4. Should my indemnity insurance provider impose any conditions and/or restrictions on my Indemnity insurance policy, in the future, I confirm that I will immediately notify the hospital CEO of the nature and extent of such conditions and/or restrictions.

Yes � No �

7.5. Have your clinical privileges and/or appointment at any hospital or day procedure centre ever been the subject of internal or external review, reduced, suspended or revoked or have you had conditions attached to that appointment for any reason?

Yes � No �

If you answered Yes to the above, please provide dates and particulars:

7.6. Have you ever had any restrictions / conditions placed on your Medical Registration or have you ever entered into undertakings with AHPRA or your registration board ? Yes � No �

(If you answered Yes to the above, please provide details including details of the restrictions / conditions and period during which the restrictions apply / applied):

Healthe Care Australia Pty Ltd Hospital By-Laws Mar-16

Page 10 of 11

7.7 Have you previously been refused accreditation at another health care facility? Yes � No �

(If you answered yes to the above, please provide name of the facility & rationale for refusal. Please note: A senior executive of the hospital may contact the facility)

7.8 Has your Scope of Practice or Clinical Privileges been restricted, suspended, not renewed or have you been the subject of adverse or critical findings as part of an internal or external review initiated at any other health care facility?

Yes � No �

(If you answered yes to the above, please provide name of the facility & rationale for refusal / restriction / suspension / recommendation. Please note, a senior executive of the hospital may contact the facility).

7.9 Are you currently under investigation or have there ever been any adverse or critical findings made against you which may be relevant to your appointment (for example: with respect to patient management, behaviour, breach of insurance / medical laws, professional misconduct, sexual assaults or assault) by: Health Insurance Commission / Medicare / Professional Services Review, Medical Board / AHPRA, a Health Care Complaints Commission/body, a Coroner, Police, College, a Court or any other professional disciplinary or similar body?

Yes � No �

(If you answered yes to the above, please provide details)

7.10 Do have any illness or disability which may adversely affect your ability or fitness to practice? Yes � No �

(If you answered yes to the above, please provide details)

7.11 Criminal Record Check – have you been convicted of or pleaded guilty to a criminal offence including a serious sex or violence offence, any offence involving dishonesty or drugs, breach of any laws that regulate the provision of health care or health insurance, charged with or convicted of a criminal indictable offence (other than a spent conviction)?

Yes � No �

(If you answered yes to the above, please provide details and a copy of your current police check last three (3) months)

7.12 Working with Children – complete if applicable A Working with Children Check is required of applicants who will be undertaking direct and unsupervised contact with children in the course of their work.

WWCC Clearance Number:

7.13 Are you likely to be undertaking child related work meeting the definition above? Yes � No �

Healthe Care Australia Pty Ltd Hospital By-Laws Mar-16

Page 11 of 11

7.14 If you answered yes to the above question, do you consent to make a prohibited Employment Declaration and a Background Check, as prescribed by the relevant law? Yes � No �

Please attach your current Working With Children Clearance Certificate to this application

Secti on 8 Emergency Contact

Please nominate a medical practitioner accredited at the Healthe Care Australia Hospital with an equivalent scope of practice where you are seeking accreditation who has agreed to be contacted and deputise for you in the event that you are unavailable. (NB: Not applicable for Surgical Assistants):

Name:

Specialty:

Contact Numbers: Home: Mob: Pager:

Facility:

Specialist Directory: (Not applicable to surgical assistants)

• I authorise the Hospital to include my details in the Hospitals Specialist Directory Yes � No �

Authority:

• I hereby apply for accreditation at Maitland Private Hospital for the clinical privileges I have specified and as attached to this application.

• In making this application I acknowledge and agree that:

� I have received a copy of the Healthe Care Australia Pty Ltd Hospital By-Laws.

� I have read and understood the Healthe Care Australia Pty Ltd Hospital By-Laws.

� If I am appointed I accept all of requirements set out in, and will comply in full with, the Healthe Care Australia Pty Ltd By-Laws, as amended from time to time.

� The Hospital executives, its officers and the medical advisory committee may seek information about my past experience, clinical performance and current fitness.

� If I have provided misleading, deceptive or inaccurate information or information which is likely to mislead, deceive or be inaccurate (including through omission), Healthe Care Australia Pty Ltd may (in its absolute discretion) immediate proceed to suspension or termination of my Accreditation.

� I will immediately notify the CEO of Maitland Private Hospital of any material changes or additional relevant information with respect to the information already provided by me in connection with this application so that it remains accurate while the application is under consideration.

� I will also notify the CEO in any of the following events (but not limited to the following events):

� The relevant statutory professional registration board makes an adverse finding against me or suspends, revokes or places any limitation on my registration;

� I do not have professional indemnity insurance cover in place for any reason;

� I am convicted of a serious criminal offence

� I understand that my Appointment as an Accredited Practitioner, if granted, will be reviewed in 5 years or earlier if considered necessary.

Applicant’s Name:

Signature Date:

Witness Name:

Signature: Date:

Search for a specialist listing I wish to participate in the search for a specialist data base YES � NO� (Please tick) Electronic Photo supplied for inclusion on listing YES � NO� (Please tick) If participating, please provide details below that you would like to display on our site *Title

[Salutation]

*First Name

*Last Name

Reg. Number:

Pra

ctic

e In

form

atio

n

*Practice / Clinic Name:

*Address (Street)

*Suburb

*State *PostCode

*Phone Fax:

Email (General Enquires)

Web Address (practice) Link to site �

*Speciality [as per attached list and as credentialed]

-Sub speciality

-Sub speciality

-Sub speciality

*Hospital [Please supply one form per HCA Hospital where credentialed]

Other hospital appointments [Public and private appointments]

Qualifications

Languages Spoken

I confirm the above information is current and correct. I also consent to having these details published on the ‘Search for a Specialist Database’ both on the Healthe Care Group website and associated hospital website for public viewing. I will advise of any future changes as they occur. _____________________________________ ____________________ Signature Date Please return this form either by hand, fax or email to the Executive Assistant at Maitland Private Hospital. Fax: (02) 4933 8883 or Email: jacqueline.sharkey@healthecare.com.au Photos will need to be emailed in an appropriate image format (jpg, tif, png, bmp)

HEALTHE CARE AUSTRALIA PTY LIMITED

MAITLAND PRIVATE HOSPITAL (ABN: 90 086 450 660)

Authority to Obtain Medical Board Registration and Insurance Details

Consent Form

I, ________________________________________, hereby give Maitland Private

Hospital consent to obtain information relating to my insurance from my insurer.

This information will only be used for the purposes of providing evidence of

insurance renewal. This consent will continue in perpetuity unless otherwise

rescinded in writing.

Signature:__________________________________________________

Name:_____________________________________________________

Date of Birth:_______________________________________________

Address:___________________________________________________

__________________________________________________________

Specialty:__________________________________________________

Date:_____________________________________________________

Authority to Release Information I, ______________________________________________________ , Avant Insured’s Full Name

Avant Member ID __________________________________________ Member Code or Member Number

hereby authorise Avant Insurance Limited (ACN 003 707 471) to provide

confirmation of my indemnity insurance to the medical facility/ies(named in full) listed as

follows: ________________________________________________________ ________________________________________________________ The information provided may include the following details:

name

address

Avant member ID

policy number

policy start and end dates

policy limit

category of practice

State of practice This authority will continue until otherwise revoked in writing by myself. Signed: _______________________________ Date: _________________ Avant Insured’s Signature

This completed form should be returned to Avant Insurance Limited:

by fax to 1800 228 268

by mail to PO Box 746, Queen Victoria Building NSW 1230

The MDA National Group is made up of MDA National Limited ABN 67 055 801 771 and MDA National Insurance Pty Ltd (MDA National Insurance) ABN 56 058 271 417 AFS Licence No. 238073. Insurance products provided by the MDA National Group are underwritten by MDA National Insurance.

Privacy: The MDA National Group collects personal information to provide and market our services or to meet legal obligations. We may share personal information with other organizations that assist us in doing this. You may access personal information we hold about you, subject to the Federal Privacy Act. If you wish to change your contact details or to be removed from our mailing lists or for more information or to see our Privacy Policy, please contact us at 1800 011 255.

When contacting MDA National Insurance on your behalf, the authorised person will be asked for your password as verification before any information is disclosed. This process will eliminate you having to provide written authorisation for each associate. It is your responsibility to provide your password to associates and keep it confidential. MDA National Insurance will not be responsible for verifying that any person using your password has been properly authorised by you to do so. Your nominated password can be changed at any time by contacting MDA National Insurance and the authorisation will remain current until it is revoked by you.

Third Party Disclosure Authority

MDA National Insurance is occasionally requested by a third party to provide details of your current status to confirm that

you have indemnity insurance in place. This information is usually requested by hospitals, employers, employees and medical

boards. If you wish to enable authorised associated parties, such as your practice managers, to obtain information on your

behalf you can nominate a password below and provide it to your associates.

Name________________________________________________ Member Number__________________________

1. Do you authorise MDA National Insurance to provide confirmation of your indemnity

cover to a third party? YES NO This information will include your Name, Address, Membership Number, State of Practice, Policy Number, Policy Dates, Specialty and Policy Limit.

2. Do you authorise a Hospital or Practice that you work at to obtain a Certificate of

Currency on your behalf? YES NO

If YES, please provide the Hospital or Practice name(s).

______________________________________________________________________________________

______________________________________________________________________________________

3. Do you wish to enable authorised associated parties, such as your practice managers,

to obtain information on your behalf? YES NO

If YES, please tick the appropriate disclosure preference below and nominate a password.

Information regarding my Membership of MDA National or my Professional Indemnity Insurance Policy issued by

MDA National Insurance, but not including any information pertaining to any incidents I have reported to you or

claims made against me.

Other (please provide details) ________________________________________________________

PASSWORD (Limit of 8 Characters)

Please Sign and Date

Signed Date / /

Please return this form to us by one of the following:

Email: peaceofmind@mdanational.com.au

Fax: 1300 011 244

Post: MDA National, Reply Paid 85186, SOUTHBANK VIC 3006

Delegation of Authority

Medical Indemnity Protection Society | ABN 64 007 067 281 | AFSL 301912 | 1800 061 113 | mips.com.au PF201305155 | Page 1

Please ensure that you read the important information section above. All sections are to be completed, please print clearly.

Step 1: Member detailsTitle

Surname

First names

Member number

Date of birth D D / M M / Y Y

Mobile | |

Business Hours | |

Email (please print clearly)

Step 2: Nominated representativeTitle

Surname

First names

Business name (if applicable)

Business address (if applicable)

Address

Suburb

Postcode State

Country

Relationship (eg spouse)Date of birth D D / M M / Y Y

Mobile | |

Business Hours | |

Email (please print clearly)

Step 3: Member declarationI authorise MIPS to provide personal information relating to my membership such as the category of my membership, my period of membership cover and any other details relevant to demonstrating that I am a member, to the nominated business or individual representative outlined above. I understand I may revoke this delegation at any time by advising MIPS. I understand it is my responsibility to advise MIPS if any existing delegation of authorities is to be removed.

I authorise my nominated representative to make amendments to my membership contact details (e.g. correspondence address): No Yes

Signature

Date D D / M M / Y Y

Important information • MIPS is bound by the national privacy principles contained in

the Privacy Act 1998 (Cth), and is unable to provide any details regarding your membership to anyone other than yourself without your written authority.

• This form should be used by members who wish to allow a third party (ie a ‘nominated representative’) such as spouse, relative, practice manager or employer to obtain information regarding their MIPS membership or if nominated make amendments to their membership contact details.

• The nominated representative will not be able to make changes to membership details (eg membership category or practice state, cancel membership or access any non-membership information such as claims data).

• Requests are replied to by email to the nominated representative.

• Nominated businesses authorities (eg organisations/hospitals) will be held with the business not an individual.

• Individuals nominated by a business will be used as a contact person only.

• Contact number, email and relationship (eg spouse, relative, employer, and practice manager) must be provided for all delegations.

• Date of birth is not required for nominated businesses.

Completed application forms can be mailed or emailed. PO Box 25 Carlton South Vic 3053 | info@mips.com.au

Fact sheet 4 Exemptions July 2014

Part 4, Clause 20 of the Child Protection (Working With Children) Regulation 2013 If you are in child-related work but you qualify for one of the following exemptions, you do not need to apply for a Working With Children Check.

• Administrative, clerical or maintenance work, or other ancillary work,

that does not ordinarily involve contact with children for extended

periods (other than a school cleaner).

• A worker who works for a period of no more than five days in a

calendar year, if the work involves minimal direct contact with children

or is supervised when children are present.

• Informal domestic arrangements not carried out on a professional or

commercial basis.

• Work with close relatives of the worker (not including work as an authorised carer foster

carer or other authorised carer of children in statutory and supported out-of-home care).

• Volunteering by a parent or close relative:

of a child in activities for the child’s school, early education service or other

educational institution; except where the work is part of a formal mentoring

program or involves intimate personal care of children with a disability

with a team, program or other activity in which the child usually participates or is

a team member; except where the work is part of a formal mentoring program or

involves personal care of children with a disability.

• A visiting speaker, adjudicator, performer, assessor or other similar visitor at a school or

other place where child-related work is carried out if the work of the person at that place is

for a one off occasion and is carried out in the presence of one or more other adults.

• A health practitioner in private practice, if the practice does not ordinarily involve treatment

of children without one or more other adults present.

• A health practitioner who is working in and visiting NSW from outside the State, if the

period of work does not exceed a total of five days in any period of three months.

• A co-worker or work supervisor where a child works.

Scan to view our Online tutorials

Suite 1, Level 13, 418A Elizabeth Street Surry Hills NSW 2010

Check: 02 9286 7219 Fax: 02 8219 3699

ABN 43 304 920 597 www.kidsguardian.nsw.gov.au/check Email: check@kidsguardian.nsw.gov.au

• Work by an interstate visitor:

in a one-off event such as a jamboree, sporting or religious event or tour, if the

event is the only child-related work carried out by the worker in NSW in that

calendar year and the period of work does not exceed 30 days

who holds an interstate working with children check, or is exempt from the

requirement to have such a check in his or her home jurisdiction, whose child

related work in NSW is for no more than 30 days in any calendar year.

• NSW Police or Australian Federal Police officers in their capacity as police officers.

• Home carers accredited with a current police certificate for aged care, for home care work where the clients are not primarily children.

• People under the age of 18.

Part 2 of the Child Protection (Working With Children) Regulation 2013 Some work is not considered to be child-related, which means it will not require a Working With Children Check. This work is set out in: Clause 6 (4) Work as a student on professional placement in the course of a student

clinical placement in a hospital or other health service is not child-related work.

Clause 7 (3) Work as a referee, umpire, linesperson or otherwise as a sporting official or a

groundsperson is not child-related work, if the work does not ordinarily involve contact with

children for extended periods without other adults being present.

Clause 8 (2) Work in providing respite care or other support services primarily for children

with a disability is child-related work; but it is not child-related work if the work does not

ordinarily involve contact with children for extended periods without other adults being

present.

Clause 11 (3) Providing food or equipment at or for a sporting, cultural or other

entertainment venue or providing a venue is not child-related work.

For more information, please refer to the fact sheets and resources page of the website www.kidsguardian.nsw.gov.au/check.

If you have a question, please email us at check@kidsguardian.nsw.gov.au.

Disclaimer: The material provided in this Fact Sheet is for guidance only. Every effort has been made to ensure that the information is accurate, current and not misleading. However, this cannot always be guaranteed and no warranty is given that the information is free from error or omission. Users should exercise their own skill and care with respect to the use of the material. The information is also not a substitute for independent legal or other professional advice and users should obtain appropriate professional advice relevant to their particular circumstances. The Office of the Children’s Guardian does not guarantee, and accepts no legal liability whatsoever for any act done, omission made, loss, damage, cost or inconvenience arising from, connected to, or as a consequence of, using or relying on the material contained in this Fact Sheet.

Working With Children Check – Fact sheet 4: Exemptions 2

Suite 1, Level 13, 418A Elizabeth Street Surry Hills NSW 2010

Check: 02 9286 7219 Fax: 02 8219 3699

ABN 43 304 920 597

www.kidsguardian.nsw.gov.au/check Email: check@kidsguardian.nsw.gov.au

Fact sheet 16 How do I apply? July 2014

If you are starting a new paid job in child-related work in NSW, you need to apply for a Working With Children Check. If you are currently employed or you volunteer in child related work, please see FACT SHEET: Phase-in schedule and FACT SHEET: Exemptions on our Fact sheets and resources web page.

If you are applying from overseas or interstate, please see FACT SHEET: Overseas applicants or FACT SHEET: Interstate applicants.

STEP 1: Complete an online application form

• Go to www.kidsguardian.nsw.gov.au/check and complete the online application form. If you do not have access to the internet, please telephone (02) 9286 7219 for assistance.

• Please make sure the details you provide are EXACTLY THE SAME as the details on your identity documents. If you have submitted the form with a mistake, please redo the form to avoid problems with the proof of identity requirement at step two.

• Ensure you select the correct category: paid or volunteer worker. The $80 fee for paid workers is not refundable if you are a volunteer and you choose ‘paid worker’ by mistake. A Check for paid workers will cover both paid and volunteer work in NSW for five years.

• Once you have submitted the form, you will receive an application number that looks like this: APP1234567.

Need help? Watch the online tutorial on YouTube. More video tutorials are available on our website: Online tutorials.

STEP 2: Present proof of your identity • Go to a NSW Motor Registry, RMS agency, or Service NSW office (not your local Council).

Find a location at www.service.nsw.gov.au/service-centre. • You will need your application number and proof of your identity. You must have both of

these items for your application to proceed. • If you are in paid work, you will also be required to pay an $80 fee for a five year clearance.

See FACT SHEET: Fee information.

Scan to view our Online tutorials

PLEASE NOTE: Before you go to submit your proof of identity

• You cannot submit proof of identity on behalf of someone else. You must appear in person with your own documentation.

• Proof of identity cannot be performed outside of NSW. It must be completed at a NSW Motor Registry, RMS Agency, or Service NSW office.

• Additional identity verification options are available for authorised carers and their adult household members who live interstate, and for those who are medically unable to attend a motor registry or RMS Agency. See FACT SHEET Interstate or incapacitated authorised carers or householders: Identity verification options.

Receiving your results You will receive your outcome and Working With Children Check number by email (or post if you do not have an email address). See also FACT SHEET: When will I receive my results? If you have not received your results within four weeks, please email your details and application number to check@kidsguardian.nsw.gov.au.

Find a NSW motor registry Locations of Motor Registries, RMS Agency, or Service NSW offices can be found at www.service.nsw.gov.au/service-centre.

More information For more information, please go to the Frequently Asked Questions (FAQ) available from at www.kidsguardian.nsw.gov.au/check.

If you have a question, please email check@kidsguardian.nsw.gov.au.

Disclaimer: The material provided in this Fact Sheet is for guidance only. Every effort has been made to ensure that the information is accurate, current and not misleading. However, this cannot always be guaranteed and no warranty is given that the information is free from error or omission. Users should exercise their own skill and care with respect to the use of the material. The information is also not a substitute for independent legal or other professional advice and users should obtain appropriate professional advice relevant to their particular circumstances. The Office of the Children’s Guardian does not guarantee, and accepts no legal liability whatsoever for any act done, omission made, loss, damage, cost or inconvenience arising from, connected to, or as a consequence of, using or relying on the material contained in this Fact Sheet.

Working With Children Check – Fact sheet 16: How do I apply? 2