OUTREACH NEW PROVIDER REGISTRATION

Transcription

1 OFFICE USE CONTRACT DRAFTED: CONTRACT RECEIVED: ORS: NAV: CYNDI: PHONE FAX STREET Level 2, 55 Russell Street South Brisbane QLD 4101 POST PO Box 3205 South Brisbane QLD 4101 checkup.org.au OUTREACH NEW PROVIDER REGISTRATION (To be completed by Contracted Organisation/HHS or Individual Provider) ORGANISATIONAL/PERSONAL/PROFESSIONAL DETAILS: Title (e.g. Dr, Mr, Mrs): Full Name: Date of Birth: Gender: Male Female Specialty/Discipline: To be contracted as: Organisation/HHS OR Contractor/Private Provider Company/Org/HHS/ Practice Name (if applicable): Trading As Company/Org/HHS/ Practice Physical Address: (This address will appear on your contract) Postal Address: Suburb: Postcode: Suburb: Postcode: p1 of 6 F036: V2: Nov2016

2 Contact # Address: Work: Mobile: Fax: Preferred method/s of contact: Work Phone Mobile Fax Post Additional Contact Information Is the person completing this form carrying out the work? If No, Contact Name of person performing the service: Yes No l Address: Name of person who has Contract signoff authority: (if different to Provider) Address: Financial Contact Name: (for receiving payment invoices) Address: p2 of 6

3 Alternative Contact: (e.g. Practice Manager, Personal Assistant etc.) Name: Contact no: PAYMENT DETAILS: Please list the business entity you wish to be paid and reimbursed to: Company/Trading As: ABN #: Are you registered for GST? Yes No Bank name and Branch: BSB number: Account number: Account name: INSURANCE INFORMATION: It is mandatory that you have your own insurance with adequate coverage (minimum $10 million cover for professional Indemnity and Public Liabaility) for the scope of clinical practice for which you are providing services. A copy of your up-to-date certificate of currency must be held with CheckUP at all times. Please ensure you attach a photocopy of the Certificate of Insurance for Each of the policies relevant to your practice and that these certificates are Current. Attached Professional Indemnity (Org/HHS/Indiv) Public Liability (Org/HHS) Workers Compensation (Org/HHS) Non Applicable Does your Professional Indemnity Insurance fully cover the scope of clinical practice you have applied for? Yes No p3 of 6

4 CREDENTIALING (Contractor/Private Provider to complete) Professional Registration Number: Expiry Date: Audiology Audiology Australia Speech Pathology - Speech Pathology Australia Dietetics Dietitians Association of Australia Diabetes Education Australian Diabetes Educators Association Please provide CheckUP with a copy of your Registration Certificate/s Please record the facilities and / or organisations you are currently credentialed with (i.e. Hospital and Health Service, Private Hospital Please provide CheckUP with a copy of proof of credentialing Has there been any adverse findings made against you or any provider delivering these services which would be relevant to you/them providing the service/s you have applied for by the Health Insurance Commission, a Health Registration Board, a Health Care Complaints Commission/Body, a Coroner, a Court or any other professional? Yes No If yes, and if not prevented by confidentiality agreements, could you please provide a brief description of each adverse judgement or settlement, and the year in which the event occurred? p4 of 6

5 CREDENTIALING (ORGANISATION/HHS TO COMPLETE) Are the provider/s delivering the Outreach services registered with the appropriate Registered body (e.g.. Audiology Australia, Dietitians Assn) and fully covered for the scope of clinical practice they will be delivering? Yes No INSURANCE INFORMATION: Have you undertaken any Cultural Awareness Training (this could include cultural awareness training conducted in a group or individual setting or alternatively from extensive service delivery experience in Aboriginal and Torres Strait Islander communities)? Yes No Please outline the training you have undertaken including any experience providing services in Aboriginal and Torres Strait Islander communities: If you responded NO, please detail below how you will fulfil this requirement within three (3) months of contract execution: p5 of 6

6 DECLARATION: I declare that the information that I have provided is accurate and complete, and that I will comply in every respect with the By-Laws, the Medical Act 1939 (as amended) and the code of conduct of any medical college/professional association of which I am a member. I declare that all contracted services will be delivered by a Health Provider or an Employee who is an appropriately trained, qualified, registered and insured Health Professional. I declare that I do not have a condition which would affect my ability to exercise the scope of clinical practice completely. I declare that my medical indemnity/professional indemnity cover is adequate and appropriate for the activities undertaken in my scope of clinical practice. I undertake to notify CheckUP should any information provided in this registration form varies in any way. AUTHORISED SIGNATORIES: (ORGANISATION/HHS ONLY) Service Owner/Executive Service Owner/Executive Officer #1 Officer #2 (Sole Trader, Director, Trustee, Partner) (Sole Trader, Director, Trustee, Partner) Print Name: Print Name: Signature: Signature: Date: Date: Please return this completed form and required documentation to CheckUP s Outreach Services Team via , fax or post. outreachservices@checkup.org.au Fax: (07) Post: CheckUP, PO Box 3205 South Brisbane QLD 4101 For further information please contact the Outreach Services team on p6 of 6