ACCREDITATION FORM SCHEDULE 5 APPLICATION FOR …

ACCREDITATION form SCHEDULE 5 APPLICATION FOR APPOINTMENT AS AN accredited practitioner authority declaration **Please complete, upload and attach this authority declaration form to your online APPLICATION where prompted, to enable the APPLICATION to be submitted to Healthscope** APPLICANT DETAILS Title: DR MR MRS MISS A/PROF PROF OTHER: Surname of Applicant: First Name in full: PRIVACY NOTICE Healthscope Operations (Pty Ltd) collects the personal (including sensitive) information requested in the form for the purpose of assessing your APPLICATION to be a Healthscope Hospital accredited practitioner . If you do not provide all the information required, then your APPLICATION cannot be assessed by any Healthscope Hospital.

ACCREDITATION FORM – SCHEDULE 5 APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER AUTHORITY DECLARATION **Please complete, upload and attach this authority declaration form to your online application

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