Outer Metropolitan Other Medical Practitioners Relocation Incentive

More Doctors for Outer Metropolitan Areas Measure
Outer Metropolitan Other Medical Practitioners Relocation Incentive Programme
Application Form
Outer Metropolitan Other Medical Practitioners Relocation Incentive Programme Application Form
Application for Retention Component
Important Notice
This form must be completed if you wish to apply for the Retention Component of the Outer
Metropolitan Other Medical Practitioners Programme of the More Doctors for Outer
Metropolitan Areas Measure.
The grant information package can be found at:
(www.health.gov.au/internet/main/publishing.nsf/Content/work-pr-omompp)
For advice on the RIG or assistance with this application, please call the Outer Metro Hotline
on 1800 727 899.
Completed applications may be sent to:
The Delegate
More Doctors for Outer Metropolitan Areas Measure
MDP 152 GPO Box 9848
CANBERRA ACT 2601
Email: [email protected] All applications will be acknowledged.
Please note: Medicare provider number information supplied on this form will be checked to
validate your eligibility for the RIG.
Please answer each question and tick the boxes where appropriate.
Page 2 of 6
Outer Metropolitan Other Medical Practitioners Relocation Incentive Programme Application Form
Part 1 PERSONAL INFORMATION
Family name:
First names:
Postal address:
Contact Details
Please indicate preferred method of contact by ticking the corresponding box
Daytime phone number:
☐
Mobile phone number:
☐
Fax number:
☐
Email address:
☐
Provider Number Information
Medicare provider number/s:
When did you gain your unconditional (general) medical registration in Australia?
Date:
Are there any conditions on your medical registration?
No ☐
Yes ☐
Are there any restrictions on the use of your Medicare provider number?
(This includes restrictions under sections 19AA and 19AB of the Health Insurance Act 1973)
No ☐
Yes ☐
Page 3 of 6
Outer Metropolitan Other Medical Practitioners Relocation Incentive Programme Application Form
No.1 practice location
Practice name:
Street number:
Street name:
Suburb:
State:
Postcode:
No. 2 practice location
Practice name:
Street number:
Street name:
Suburb:
State:
Postcode:
Please attach the practice addresses for any additional practices.
Additional Qualifications:
Page 4 of 6
Outer Metropolitan Other Medical Practitioners Relocation Incentive Programme Application Form
Part 2 RACGP FELLOWSHIP
PATHWAY TO FELLOWSHIP (FRACGP) CONDITIONS
It is a requirement of the retention component of the Programme that a participating medical
practitioner be either enrolled in a course based pathway leading to Fellowship or enrolled in
assessment for Fellowship.
In line with this, the Delegate will require upon application written evidence of enrolment as
follows:
•
•
enrolment in any other course based pathway recognised by the RACGP;
enrolment in assessment for Fellowship encompassing assessment by examination or
practice based assessment.
Documents Attached
No ☐
Yes ☐
Expected completion date of Fellowship
Comments: Use this space to provide additional information on completing a pathway to
Fellowship of the RACGP, as required in the Programme Guidelines.
Page 5 of 6
Outer Metropolitan Other Medical Practitioners Relocation Incentive Programme Application Form
Part 3
DECLARATION AND CONSENT OF INFORMATION
Privacy Note
The information provided by you on this form will be used to assess your eligibility to
participate in the Outer Metropolitan Relocation Incentive Grant Programme. Where
appropriate, and in order to ensure correct administration of the Programme, information may
be exchanged between the Department and Medicare Australia for the purposes of
administering, monitoring, reviewing and evaluating the Programme.
Applicants should note that part of the Programme’s administration process is to publicise the
suburb and postcode to which the doctor is relocating on the Department’s website. No
personal information will be disclosed. Any information you have supplied to Medicare
Australia and/or the Department of Health in connection with your application for the
Programme will be dealt with in accordance with the provisions of the Privacy Act 1988, and
in particular, the Information Privacy Principles set out in section 14 of that Act.
Declaration
I declare that the information I have supplied in this form is true and correct. I consent to the
release of information by Medicare Australia to the Department of Health, or vice versa, for
the purposes of administering, monitoring, reviewing and evaluating the Programme. I
understand that part of the administration process is to publicise the suburb and postcode to
which I am relocating on the Department’s website.
Signature
Date
I understand that there are penalties for supplying false or misleading information regarding
provider numbers and practice locations.
Consent for use of personal information for marketing and promotional purposes
Occasionally, the Department may require doctors’ personal information for the purpose of
marketing and promoting the Programme. The information required for these activities are
generally the doctor’s name and the name and address of the practice to which the doctor is
relocating. In addition, the doctors’ contact phone number and email address may be
provided to the body conducting the promotion so that they may make direct contact (i.e. not
for public dissemination). Doctors’ Medicare provider numbers will not be included with this
information. In accordance with the provisions of the Privacy Act 1988, the Department will
only disclose this information with the doctor’s consent.
Please indicate your consent below by ticking the appropriate box:
I consent to the disclosure of my personal information for the purpose of marketing and
promoting the More Doctors for Outer Metropolitan Areas Measure. I understand that by
providing my consent, I may be contacted by a representative from the Department of Health
or a promotional organisation to participate in publicity campaigns for the More Doctors for
Yes ☐
Outer Metropolitan Areas Measure.
Signature
Date
Page 6 of 6
No ☐