FODO BUSINESS MEMBERSHIP APPLICATION 2017

Transcription

1 FODO BUSINESS MEMBERSHIP APPLICATION 2017 SECTION 1 APPLICANT DETAILS Full Name of Business Trading Name (if different) Date Business started trading Head Office Address Postcode Address Contact Name (for application) Daytime telephone Mobile Telephone Business Status: (please tick and complete as appropriate) Sole Trader Name of Sole Trader GOC Reg. No (If applicable) Partnership Partner 1 Name Partner 2 Name GOC Reg. No (if applicable) GOC Reg. No (if applicable) (Please list any further partners on a separate sheet of paper) Limited Company Limited Liability Partnership (LLP) Company Reg. No. LLP Registration No VAT Registration No. Body Corporate GOC Reg. No. (if applicable) Registered Office Address (If different from above) Postcode Daytime Telephone Name Managing Director/ (please delete as appropriate) When would you like your FODO membership to start? Date

2 Why are you applying for FODO Membership? SECTION 2 SERVICES Does the company hold GOS mandatory contract/s? Yes If yes how many? Not yet, contract applied for No Does the company hold GOS additional services contract/s? Yes If yes how many? Not yet, contract applied for No Does the company provide any of the following services? Locally Commissioned Enhanced Services Hearing services Optician services in the Republic of Ireland Optician services outside the UK or the Republic of Ireland Other services (please describe below) SECTION 3 INSURANCE COVER Does your company require FODO Professional Indemnity and Legal Defence Insurance for optical services? No (please proceed to section 6) Yes in the UK (please proceed to section 4) Yes in the Republic of Ireland (please proceed to section 4) Yes in the UK and the Republic of Ireland (please proceed to section 4) Who currently supplies your insurance cover? SECTION 4 RETROSPECTIVE PROFESSIONAL INDEMNITY AND LEGAL DEFENCE INSURANCE COVER Please note that all cases declared as part of your application, and any matters related to them, are excluded from FODO cover (unless specifically agreed by FODO in writing). Also, failure to disclose any relevant information could invalidate your cover. Applicants are advised that, if they change insurance provider they would normally need to purchase run-off cover from the previous provider or retrospective cover from the new provider. FODO retrospective professional indemnity insurance will cover you or the business for the professional work you have carried out since January Does the business require retrospective professional indemnity and legal defence cover? Yes No If no please answer the question below If a claim comes in relating to an incident before you joined the FODO scheme, does the business have cover for it? Yes No If yes who is providing the cover?

3 SECTION 5 CLAIMS HISTORY Please note that all cases declared as part of your application, and any matters related to them, are excluded from FODO cover (unless specifically agreed by FODO in writing). Also, failure to disclose any relevant information could invalidate your cover. A. In the past ten years have any compensation claims been made against your company or against any practitioners whilst they were working for or engaged to provide services by your company? No Yes (please give details, including dates and outcome) B. In the past ten years have any GOC investigations or Fitness to Practise hearings been instigated against you, a partner, director or against any practitioners employed by or providing services for your company? No Yes (please give details, including dates and outcome) C. Is your company or any practitioners whilst working for or engaged to provide services by your company currently dealing with any complaint / dispute which may lead to a compensation claim or GOC investigation? No Yes (please give details)

4 D. Are you aware of any other issues or circumstances that may affect your application? SECTION 6 FULL TIME EQUIVALENTS A. Please enter total number of practices No of practices in the UK No of practices in the Total number of practices Republic of Ireland Please state number of practices that are: Wholly owned Joint Venture Franchise Other If other please give details B. Please enter total number of Full-Time Equivalents (FTEs) in the UK (see calculation method below) Both employees and self-employed practitioners should be included. Employees with a dual role (i.e. Contact Lens Opticians and Dispensing Opticians) need only be counted once in their respective boxes. Dispensing Opticians Contact Lens Opticians Optometrists Ophthalmic Medical Practitioners Total number of FTEs in the UK C. Please enter total number of Full-Time Equivalents (FTEs) in the Republic of Ireland (see calculation method below) Both employees and self-employed practitioners should be included. Optometrists Dispensing Opticians CLOs OMPs Total number of FTEs in the Republic of Ireland How to calculate the FTE number: Members insurance cover is calculated on the basis of the number of full-time equivalent (FTE) registered practitioners (optometrists, dispensing opticians, contact lens opticians, ophthalmic medical practitioners) working for or providing services for the member (including self employed practitioners and/or locums). Count the number of half days each registered practitioner works each week. Use fractions for anyone working less frequently than every week. Add the figures together and divide by 10 to obtain the FTE number. The minimum total FTE is 1. Example: 1 optometrist working 3 days per week = 6 half days 1 dispensing optician working 2 days per week = 4 half days Total = 10 half days 10 half days divided by 10 = 1 full time equivalent (FTE)

5 SECTION 7 AUDIOLOGY Do you require insurance cover for audiology? Yes No How many audiologists provide services for your company in the UK? How many audiologists provide services for your company in the Republic of Ireland? Do you require retrospective professional indemnity cover for audiology? Yes No SECTION 8 REFERENCE Please provide two references that you are happy for us to contact (ideally at least one of these from an existing FODO member). One reference should be from a clinical referee and GOC registrant who is not employed or engaged by your company. The other should be a reference from a company or person which can vouch for your organisation. Suitable referees would be anyone working in (or recently retired from) a recognised profession who has knowledge of your practice or business e.g. accountant, solicitor, LOC/ LEHN/ CCG chair or person of similar standing in the local community. For start-up practices please provide a clinical reference for the person running the practice along with a personal reference that can vouch for professional integrity. If one of your references is not from an existing FODO member, please explain why in the box below. Reference 1 Company Contact Name Address Postcode Telephone Reference 2 Company Contact Name Address Postcode Telephone

6 SECTION 9 MEMBERSHIP CRITERIA FODO Membership Criteria Members are expected to conduct their business according to statutory regulations currently in force and the GOS terms of service, ABDO and College of Optometrists guidelines, and the GOC Code of Conduct. Members agree that they will not act in a way that would bring the reputations of the profession or of FODO into disrepute. Members agree to abide by any conditions of membership as may, from time to time, be stipulated by FODO (Current version attached). Do you agree to the FODO Membership Criteria? Yes No If no please specify why SECTION 10 DECLARATION I hereby apply on behalf of the business for Membership of the Federation of (Ophthalmic and Dispensing) Opticians (FODO) and understand that acceptance of this application is subject to the approval of the Board of Directors. I confirm on behalf of the business that I am happy to meet FODO quality criteria. I confirm on behalf of the business that all the information I have given on this form is correct. If any information is found to be incorrect this could invalidate insurance cover and/or membership of FODO. Authorised Signatory Position Print Name Date Please return to: Member Services, FODO, 199 Gloucester Terrace, London W2 6LD Tel: membership@fodo.com We will acknowledge receipt of your application within 24 hours (Mon Fri). We will process your application as quickly as possible and may contact you if we need further information. We aim to confirm the outcome within 21 days.

7 SECTION 11 DATA PROTECTION FODO, as a body that processes personal information, aims to comply with the eight principles of data processing under the Data Protection Act Personal data shall be processed fairly and lawfully 2. Personal data shall be obtained only for one or more specified and lawful purposes, and shall not be further processed in any manner incompatible with that purpose or those purposes. 3. Personal data shall be adequate, relevant and not excessive in relation to the purpose or purposes for which they are processed. 4. Personal data shall be accurate and, where necessary, kept up to date. 5. Personal data processed for any purpose or purposes shall not be kept for longer than is necessary for that purpose or those purposes. 6. Personal data shall be processed in accordance with the rights of data subjects under this Act. 7. Appropriate technical and organisational measures shall be taken against unauthorised or unlawful processing of personal data and against accidental loss or destruction of, or damage to, personal data. 8. Personal data shall not be transferred to a country or territory outside the European Economic Area unless that country or territory ensures an adequate level of protection for the rights and freedoms of data subjects in relation to the processing of personal data. Personal details will be held on computerised and paper-based systems. The data collected will only be used to maintain and update membership records and will not be passed to a third party unless required by law. THANK YOU

8 Additional Criteria for Corporate Membership Corporate and business members will be a business or company (incorporated under the Companies Act 2006 or non-uk equivalent), co-operative society, friendly society, limited liability partnership, other partnership or sole trader have a place of business or provide eye health or eye care services within the United Kingdom, Channel Islands, Isle of Man or Republic of Ireland be either registered as an optical body corporate with the appropriate professional regulatory body in the United Kingdom or Republic of Ireland or have satisfied the Board of Directors (in a format specified by the Board of Directors) that they comply with the UK General Optical Council s code of conduct for business registrants (or similar code promulgated by the Opticians Board in the Republic of Ireland) have satisfied the Board of Directors (in a format specified by the Board of Directors) that they comply with all relevant and ethical business practices (as may be defined by the Board of Directors from time to time and in particular cases) ensure that employees who are clinicians providing services to patients and the public meet the criteria for individual membership above in the case of providers of NHS services, that employees who are clinicians providing services to patients and the public are also on the performers list of any appropriate NHS body in the case of domiciliary providers, comply with such code or codes or practice for domiciliary providers and related guidance that the Optical Confederation may from time to time publish. Agreed and published by the Board of Directors pursuant article 28(3)(b) of the Articles of Association of the Federation on 8 November 2011.