2.2 BG REGISTRATION (Hospital Doctor) Logo
  • A LITTLE ABOUT YOU...:

  • Personal Details

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  • Current Address

  • Previous Addresses

  • Occupational Details

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

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  • 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.



  • 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

     

     

  • 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.
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  • Clear
  • About Your Health

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  • 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.
  • 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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  • Clear
  • Final page...

  • Spin the wheel

    If you know any friends who would benefit having a chat to us too you could win some awesome prizes each month in our spin the wheel competition.
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  • Authority

    I grant permission for the Blugibbon team to complete the required forms with the corresponding answers from this form.
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  • Clear
  • Should be Empty: