1. No category

Application for Re-Accreditation
as a Monash Health GP Obstetrician – (Antenatal Care only)
for the triennium 1st January 2014 – 31st December 2016
GP Obstetricians are accredited to provide antenatal care in conjunction with Monash Health hospitals
(Dandenong Hospital, Casey Hospital and Monash Medical Centre). This may be complete pregnancy care for
low-risk women or a shared care arrangement with a specialist obstetrician for defined conditions (as per
GP obstetrician pregnancy care inclusion / exclusion / referral Monash Health Procedure).
Medical Practitioners must satisfy themselves that they have adequate medicolegal cover to provide this
level of care. Note that this varies between different Medical Defence Organisations.
PERSONAL DETAILS
Title: ___________
Given Names: ____________________
□ Female
□ Male
Surname: _______________________
Languages spoken (other than English): ______________
PRACTICE DETAILS (Please list all practices you will be referring from)
Primary Practice: (Please indicate preferred practice for correspondence by ticking the box)
□
Practice Name:___________________________________________
Phone: __________________
Address:_________________________________________________
Fax: __________________
Mobile: ____________________
Email: ____________________________________
Provider No: _________________________
Additional Practice(s):
□
Practice Name:___________________________________________
Phone: __________________
Address:_________________________________________________
Fax: __________________
Email (if different from above): ____________________________________
Provider No: _________________________
I wish to receive information regarding Southern Health GP Education events and relevant clinical information via email?
□No □Yes
Preferred email address:_________________________
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SECTION 1: PROFESSIONAL REQUIREMENTS FOR ALL APPLICANTS
Please provide evidence of:
□ Current Unrestricted Australian Medical Registration
(Please attach copy of Medical Board Registration)
□ Current Medical Indemnity/Insurance membership
(Please attach copy of Medical Indemnity certificate)
Name MDO/Insurer
Member No
Category of Practice
SECTION 2: EVIDENCE OF CONTINUING MEDICAL EDUCATION
Please select at least one of the following options.
Option A:
□
Attendance at one of the Monash (Southern) Health annual Saturday Maternity Women’s Health Updates
(2011-2013)
Year of attendance:________________
Option B:
□
Ongoing education in pregnancy related care
Please provide details of your involvement in pregnancy related continuing medical education (CME/CPD) over the last
three (3) years and attach appropriate evidence or certificates (such as current QI&CPD statement).
A minimum of 10 RACGP Category 2 OR 40 RACGP Category 1 QI & CPD points is required
Please note that the RACGP does not recognise pregnancy related care as a separate category. Education in areas of direct
relevance to pre-conception counselling, pregnancy care, postnatal and/or neonatal care will be recognised
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Option C:
□
Supervised clinical attachment at one of Monash Health’s antenatal clinics
Date of attachment: ____________
Name of supervisor: _______________
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SECTION 3: ATTENDANCE AT ANNUAL MONASH (SOUTHERN) HEALTH ‘GP OBSTETRICIAN
UPDATE’ (presented by Professor Euan Wallace)
GP Obstetricians are required to have attended at least one of these updates between 2011-2013.
Year(s) of attendance: _______________________
Please note that if you have not completed the requirements in Section 2 and/or 3, you may still be eligible for reaccreditation if you can demonstrate completion of equivalent activities. Please attach a description of these activities for
submission to the Maternity GP Sub-committee for approval.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
SECTION 4: AGREEMENT
As a Maternity Care Affiliate of Monash Health, I agree to all of the following undertakings:
•
•
to familiarise myself with and observe the Monash Health Maternity Policies and Procedures
http://www.monashhealth.org.au/page/HealthProfessionals/Maternity/
to observe hospital guidelines in respect of mutual patients, including criteria for shared pregnancy care/hospital
review/referral
to participate in appropriate continuing professional development for the provision of my category of GP
Obstetric care
to notify Maternity Bookings (or Maternity GP Liaison) if I have decreased capacity to accept referrals from
Monash Health
to ensure the Women’s & Children’s Program has up to date preferred contact information (telephone, facsimile,
postal address, email)
to ensure the facsimile number given applies to a machine that is in a private location and procedures for handling
patient information comply with privacy principles and legislation
my Medical Registration is current and without conditions and I will notify the Women’s and Children’s Program if
my registration is suspended, cancelled or has restrictions imposed
my Medical Indemnity/Insurance will be maintained at an adequate level of cover for the duration of my
participation in GP Obstetric antenatal care
to notify Monash Health if any special condition is placed on my policy of medical indemnity insurance such as,
but not limited to, a premium loading, a deductible or an exclusion from benefit
to keep appropriate clinical records
•
when on leave or ill to make appropriate arrangements for continuing care
•
I authorise the service to provide women, their families and my medical colleagues with my practice details, areas
of interest and languages spoken
•
I acknowledge that Monash Health conducts research activities and quality assurance programs and I may be
approached to participate
I understand that Monash Health can review my accreditation status if I do not adhere to appropriate clinical
management
I acknowledge that my accreditation as a GP Obstetrician may be reviewed if I do not maintain an active level of
antenatal care provision
•
•
•
•
•
•
•
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Signature: __________________________________
Date: ________________________
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Checklist
Please note that applications will not be processed without copies of all supporting documentation.
□
Attach copy of Medical Board Registration
□
Attach copy of Medical Indemnity Certificate
□
Attach details of Continuing Medical Education
□
Documented year of attendance at an Annual GP Obstetrician Update
□
Signature
Please sign and return this form and copies of the relevant documentation to:
Ms Josie Ciotta
Monash Women’s GP Liaison Unit
c/o Birth Suites
Monash Women’s, Monash Medical Centre
246 Clayton Road, CLAYTON VIC 3168
You will be notified in writing of the success of your application. Note that accreditation applies for the triennium
(2014-2016). Reaccreditation will be required for the triennium 2017-2019. For more information on reaccreditation
please refer to the Maternity GP Liaison site at www.monashhealth.org.au/gps and follow links to Maternity GP Liaison.
For any queries please contact the Monash Women’s GP Liaison Unit on: 9594 6220.
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