Application for appointment as a Council Directed Health Assessor

1. Personal details

Salutation *

First name *

Surname *

Postal Address

Postal Address 1 *

Postal Address 2

Suburb *

Postcode *

Is your postal address the same as your practice location? *

Yes

Practice Location

Address

Suburb

Postcode

Phone number *

Mobile number *

Email address *

2. Professional experience

Please provide a brief description of your relevant professional experience (up to 500 words)

Experience *

3. Professional registration and certification

a) What is your AHPRA registration number? *

c) Please list any registered specialties or endorsements you hold? *

e) Please list any faculties or chapters in which you hold membership *

f) Please list any professional associations/organisations in which you hold membership *

g) Please list any other relevant qualifications you hold *

h) Please list any other relevant appointments (e.g. expert witness panels) *

i) Do you have more than five years’ experience in any of the following capabilities? *

Clinical neuropsychologist

Drug and alcohol physicians specialising in drug and alcohol dependence assessment and treatment

Neurologist

Other health assessment area

Psychiatrist

Psychogeriatrician

Psychologist

N/A

Please specify area (for example, rehabilitation physicians, sleep medicine physicians, pain management specialists, immunologists, ophthalmologists, cardiologists, mental health clinicians (in addition to psychiatrists) and geriatricians) *

attachment

4. Professional referee reports

Professional referee reports are required to assess whether you have the demonstrated experience within the nominated engagement.

You are required to provide at least two (2) completed and signed referee reports and your professional CV. The referee reports must relate to:

engagements during the past three years
nominated engagement types.

The Applicant Referee Report template is attached to this form.

Referees
We may contact your referees to verify or clarify any aspect of the referee report.
*Maximum file size for the referee report is 5MB and must be in PDF Format.

Please attach Referee Report 1 *

Files must be less than 5 MB.
Allowed file types: pdf.

Please attach Referee Report 2 *

Files must be less than 5 MB.
Allowed file types: pdf.

Please attach a copy of your CV *

Files must be less than 5 MB.
Allowed file types: pdf.

Telehealth / videoconferencing availability

Are you able to provide telehealth / videoconferencing assessments? *

Yes

If yes, please let us know how this facility is accessed by the practitioner and any other requirements for providing this service. *

6. High priority health assessments

HPCA seeks to ensure that all new health assessments occur within 45 days of the Council referring a practitioner to a health assessment. In cases which are deemed high priority, a health assessment may be required within 14 days.

Please complete the following questions regarding high priority health assessments.

I have capacity to provide a high priority health assessment within 14 days *

Yes

In order to regularly undertake high priority health assessments, I will need to (i.e. book out one afternoon per fortnight, have a regular booking with the Council per fortnight etc)

I am able to undertake the following number of high priority health assessments per fortnight

7. Pricing framework for psychiatrists and neuropsychologists

Please complete this section if you are a psychiatrist or neuropsychologist. The payment questions below detail the maximum payment rates for standard and complex assessments. It also includes the fees payable for supplementary reports, non-attendance and cancellation fees, and fees for providing additional information or evidence to a hearing.

For further information, please refer to Schedule D – Maximum Pricing Framework in the Terms and Conditions.

a) Payment for standard psychiatric assessments will be limited to $1,640 ex GST *

I agree

I do not agree

Not applicable

b) Payment for complex psychiatric assessments will be limited to $2,050 ex GST *

I agree

I do not agree

Not applicable

c) Payment for standard neuropsychological assessments will be limited to $3,280 ex GST *

I agree

I do not agree

Not applicable

d) Payment for complex neuropsychological assessments will be limited to $4,100 ex GST *

I agree

I do not agree

Not applicable

e) The cancellation fee for appointments cancelled with less than 48 hours’ notice (excluding non-working days) or non-attendance is limited to $820 ex GST *

I agree

I do not agree

f) The fee for supplementary reports is limited to $410 ex GST *

I agree

I do not agree

g) The fee for attending the NSW Civil and Administrative Tribunal, other hearings or providing advice to a hearing via phone, is limited to $410 ex GST per hour *

I agree

I do not agree

8. Pricing framework for other health practitioners

All health practitioners (other than psychiatrists and neuropsychologists) are required to complete this section. The pricing framework requires health practitioners to specify their standard fee and total time required to produce an Assessment Report

Standard fee

Working time

Hour

Minute

The pricing framework requires health practitioners to specify their complex fee and total time required to produce an assessment report.

Complex fee

Working time

Hour

Minute

I confirm that the information in this application is true and correct, and is in accordance with the Terms and Conditions for the CDHA List. *

I confirm that the information in this application is true and correct, and is in accordance with the Terms and Conditions for the CDHA List.

I agree with the Terms and Conditions for the CDHA List *

I agree with the Terms and Conditions for the CDHA List

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Medical Council of New South Wales

Application for appointment as a Council Directed Health Assessor

1. Personal details

2. Professional experience

3. Professional registration and certification

4. Professional referee reports

5. Location of professional practice and availability

Telehealth / videoconferencing availability

6. High priority health assessments

7. Pricing framework for psychiatrists and neuropsychologists

8. Pricing framework for other health practitioners