ACCREDITATION FORM SCHEDULE 5 APPLICATION FOR …

1 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.

2 You are also required to provide the personal information of others where indicated which you must ensure they agree you can disclose. Your APPLICATION will be placed in a central electronic register which can be accessed by the General Manager and/or VMO co-ordinator at each Healthscope Hospital in the relevant State. The General Manager and/or VMO co-ordinator at the Healthscope Hospital(s) to which you have applied to for ACCREDITATION will then place your APPLICATION on their Hospital's register and your APPLICATION will be assessed. Your information will also be shared with members of the relevant Hospital(s)'s Medical Advisory Committee(s) and/or Credentials Committee(s) for that purpose.

3 Healthscope Operations (Pty Ltd) may also disclose your information to your insurer and referees for the purposes of the assessment. Your personal information will otherwise be handled in accordance with the Healthscope Privacy Policy, available , which explains how you can request access to or correction of personal information we hold about you, and how you can make a complaint and how it will be dealt with. authority I hereby apply for ACCREDITATION at the hospital(s) I have specified with the Scope of Practice (clinical privileges) I have also specified. Healthscope Operations (Pty Ltd) and its Hospitals will handle the personal information I provide in accordance with the Healthscope Privacy Policy.

4 I authorise my medical indemnity insurer to provide a Certificate of Currency or equivalent including details of my medical indemnity insurance cover to the Hospital. In making this APPLICATION I acknowledge and agree: (Please initial) o I have received a copy of the Healthscope Operations (Pty Ltd) Hospital By-Laws o I will abide by the By-Laws o The Hospital(s) General Manager(s), its officers and the Medical Advisory Committee(s) or its/their Credentials Committee may seek information about my past experience, clinical performance and current fitness and current insurance/indemnity status. SIGNATURE: _____ DATE: _____