2.2 BG REGISTRATION (Hospital Doctor)

  • A LITTLE ABOUT YOU...:

  • Are you planning on working in a hospital setting?*
  • Do you plan on working in NSW Health?*

  • Personal Details

  • Date of Birth*
     - -
  • Gender*

  • Current Address

  • Previous Addresses

  • Occupational Details

  • Are you a Permenant Resident?*
  • Date you became a permanent resident
     - -

  • Medicare Provider Number (MPN)

    Blugibbon can apply for Medicare Provider Numbers via Medicare on your behalf. We need to have at least one existing MPN on file and its location including hospital name and it's full address. If it's the doctor's initial number, Blugibbon will be able to obtain a number by answering other security questions.
  • Do you have an HPI-I Number?

  • Contact AHPRA
    on 1300 361 457 to retrieve your HPI-I number.

  • AHPRA Expiry Date
     - -
  • Do you have a PRODA Account?*

  • Set One Up with Medicare
    Take me there

  • PRODA Delegacy

    Blugibbon can apply for Medicare Provider Numbers through PRODA on your behalf by assigning us as a delegate once you are logged into your account - this is both confidential and secure, but also optional. Please contact us for more details on this process once you have completed this form.

  • Clinical Referees

    4 x Senior Clinicians that can vouch for your recent experience. Please note that if you are working in NSW Health you will need 3 x Professional Referees and 1 x Clinical Referee (eg. Director) specifically that is detailed.
  • Consent to Contact Referees?*

  • Do you Plan on working in NSW Health as a locum?
  • Do You Plan to Locum with NSW Health?

  • NSW Health Policy Sign Off

    The importance of my compliance with the provisions of the following documentation has been brought to my attention by my locum agency.

  • NSW Health Policy Sign Off

    The importance of my compliance with the provisions of the following documentation has been brought to my attention by my locum agency.

    (Please tick when read – all boxes should be marked)

    PD2005_162 HIV, Hepatitis B or Hepatitis C – Health Care Workers Infected
    PD2025_024 Workplace Health and Safety - Better Practice Procedures
    PD2005_593 Privacy Manual (version 2) NSW Health
    PD2015_049 Code of Conduct
    PD2025_021 Managing Misconduct, Serious Performance and Child Related Concerns
    GL2023_012 Fatigue Management in NSW Health Workplaces
    PD2023_025 Infection Prevention and Control in Healthcare Settings
    PD2020_047 Incident Management
    PD2019_003 – New version: WWC and other Police checks
    PD2022_003 Monitoring and Managing Health Practitioners’ Compliance with Conditions on Registration

    PD2012_046 Remuneration Rates for non-specialist medical staff - short term/casual (locum)

    PD2013_036 Service Check Register for NSW Health
    PD2009_057 Records and Information Management Policy and the Records and Information Management Procedures (this can only be accessed using the hospital's intranet)
    PD2025_014 Recognition and management of patients who are deteriorating
    PD2015_045 Conflicts of Interest and Gifts and Benefits
    PD2024_015 Occupational Assessment, Screening and Vaccination Against Specified Infectious Diseases

     

     
     
  • NSW Health Policy Sign-Off: Have you read and understood the following policies?
  • NSW Health Policy Sign off - Have you read and understood the following policies?
  • Are You Currently Working for NSW Health Full Time (and plan to locum in NSW Health)?*

  • Secondary employment form for NSW Health employees only
    Please complete this form to seek approval to work as a locum in NSW Health if you are currently employed with NSW Health 

  • Declarations...

    The following questions are what we get asked about you when we fill out the client paperwork on your behalf. There a few on this page but we'll only ask you this once.
  • Have you currently (or have you been) the subject of civil proceedings related to competence or negligence issues?
  • Are you currently (or have you been) the subject of civil proceedings related to competence or negligence issues?*
  • Have you ever been refused medical indemnity insurance cover or had your premiums raised because of professional conduct, competence or negligence claims?
  • Have you ever been refused medical indemnity insurance cover or had your premiums raised because of professional conduct, competence or negligence claims?*
  • Are you currently (or ever been) the subject of and disciplinary tribunal or similar?
  • Are you currently (or ever been) the subject of and disciplinary tribunal or similar?*
  • Have you ever had conditions imposed on your registration?
  • Have you ever had conditions imposed on your registration?*
  • Have you ever been refused a license/practice certificate?
  • Have you ever been refused a license/practice certificate?*
  • Have you ever voluntarily surrendered your medical license or certificate of registration to practice medicine for any other reason than avoidance of a renewal fee?
  • Have you ever voluntarily surrendered your medical license or certificate of registration to practice medicine for any other reason than avoidance of a renewal fee?*
  • Do you have any physical or other medical conditions, including substance abuse which may limit your ability to practice?
  • Do you have any physical or other medical conditions, including substance abuse which may limit your ability to practice?*
  • Have you ever chosen to reduce your Scope of Clinical Practice?
  • Have you ever chosen to reduce your Scope of Clinical Practice?*
  • Do you accept that you may be required to supervise Junior Medical Officers?*
  • Do you accept that you may be required to work in a smaller regional/rural facility where skills at specialist level and/or work with minimal supervision?*
  • Date*
     - -
  • Clear

  • About Your Health

  • Have you ever lodged a claim for workers compensation?
  • Have you ever lodged a claim for workers compensation?*
  • Have you been involved in any motor vehicle accidents resulting in personal injury?
  • Have you been involved in any motor vehicle accidents resulting in personal injury?*
  • Have you suffered back pain or strain injury (including back surgery)?
  • Have you suffered back pain or strain injury (including back surgery)?*
  • Have you suffered from shoulder, neck or arm strain?
  • Have you suffered from shoulder, neck or arm strain?*
  • Have you had a full medical clearance for any injury identified in the questions above?
  • Have you had a full medical clearance for any injury identified in the questions above?*
  • Are you receiving any ongoing treatment for injuries identified in the questions above?
  • Are you receiving any ongoing treatment for injuries identified in the questions above?*
  • Do you suffer from any medical condition (including physical, psychiatric, psychological) for which you are receiving treatment?
  • Do you suffer from any medical condition (including physical, psychiatric, psychological) for which you are receiving treatment?*
  • Have you been vaccinated for Covid-19?*
  • Which doses have you been vaccinated with?*
  • Rows
  • Have you ever had contact with a person known to have TB?
  • Have you ever had contact with a person known to have TB?*
  • Have you been exposed to or monitored for any of the following?*
  • Have you been fit tested for a mask?*
  • Date
     - -
  • Clear

  • Getting you paid...

    If you have these details handy it will save us getting them from you once we have confirmed a placement for you.
  • Preferred method of payment
  • Preferred Payment Method*

  • For compliance purposes, we need to verify that your company has obtained each of the 3 Insurance policies as required, to ensure as a working Director and/or an employee of the company, you have the sufficient level of cover in the event of an emergency. Please upload a copy of the Certificate of Currency in the name of the company and then indicate this by confirming the Policy number next to the following types of Insurances and upload the policy:

     
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  • Are you?
  • Tax Status*
  • Do you want to claim the tax-free threshold from this payer?
  • Do you want to claim the tax-free threshold from this payer?*
  • Do you have a Higher Education Loan Program (HELP), VET Student Loan (VSL), Financial Supplement (FS), Student Start-up Loan (SSL) or Trade Support Loan (TSL) debt?*
  • Clear

  • Final page...

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  • Rows

  • Authority

    I grant permission for the Blugibbon team to complete the required forms with the corresponding answers from this form.
  • Do you wear scrubs?
  • Do you wear scrubs?
  • Date
     - -
  • Expanded Date Field (HIDDEN)
     - -
  • Clear
  • Should be Empty: