Antenatal Shared Care (ANSC) Program

Do you have clinical experience in the previous 24 months?*

Yes - Please proceed with the application

No - Currently we do not have capacity to provide clinical experience, complete section 1 & 2 to join the wait list.

Step 1

GP Details

Registrar*

Yes

No

Contact details*

First name*

Last name*

Gender*

Female

Male

Date of birth*

What is your RACGP QA&CPD Number?*

Please list (if any) languages other than English which you speak fluently and in which you would be willing to conduct ANSC consultations

Are you willing to accept referrals for ANSC for patients who do not normally attend your practice?

Yes

No

Email content for correspondence*

List any other regions or hospitals (if any) where you are accredited to provide antenatal shared care

Step 2

Contact details

Primary location contact details

Practice name*

Phone*

Practice Fax*

Email*

Practice address*

Practice Street Address*

Practice suburb*

Post Code*

Postal address

Same as office address?

Practice postal street address*

Postal address suburb*

Post code*

Additional Locations (if applicable)

Practice name

Practice phone

Practice Fax

Practice street address

Suburb

Postcode

Postal address

Practice Postal Address

Practice Postal Suburb

Practice Postal Postcode

Postal address

Same as office address?

Step 3

Professional Requirements

All applicants for Antenatal Shared Care recognition must provide evidence of each of the following:

Current Unrestricted Medical Registration in NSW

NSW Medical Registration Number

Copy of Medical Board Registration

Drop files here or

Max. file size: 20 MB, Max. files: 1.

Current Medical Indemnity/Insurance membership

Name of MDO/Insurer*

Membership Number*

Copy of Medical Indemnity Insurance

Drop files here or

Max. file size: 20 MB, Max. files: 1.

Are you appropriately indemnified with the right level of cover?

Yes

No

Step 4

Prior Experience Providing Antenatal Care

Prior Experience Providing Antenatal Care*

DRANZCOG with current recertification

Diploma Obstetrics RACOG (no recertification required) or CSCT in women’s health plus recent involvement in provision of antenatal care. Please list at least one hospital site involved

Hospital*

Contact name*

Contact number*

Additional hospital site

Hospital

Contact name

Contact number

FRANZCOG/FRAGOG

Date obtained*

Hospital experaience as an Antenatal Care Provider*

Hospital experaience as an Antenatal Care Provider

Please detail antenatal care experience with particular focus on the care of low / medium risk pregnant women (include accreditation at other hospitals, dates, contact names and phone numbers - attach separate sheet if required)

Please confirm the following

I am confident and competent in conducting antenatal palpations on women of varying gestations of pregnancy;

I am confident and competent in measuring symphysis fundal height;

I have a fetal heart rate doppler available to use within my practice;

I have a non-stretch measuring tape available to conduct fundal heights.

Step 5

Professional Referees (medical)

All applicants for ANSC recognition must provide two professional medical referees. One referee is to be a current ANSC GP or Obstetrician

Name*

Contact number*

Practice / Hospital

Position*

Name*

Contact number*

Practice / Hospital

Position*

Step 6

Agreement

As an ANSC Provider, I agree to all the following undertakings:*

As an ANSC Provider, I agree to all the following undertakings:

I have knowledge and understanding of the protocols for ANSC and will provide antenatal care in accordance with the SWSLHD / South Western Sydney PHN (SWSPHN) ANSC protocols and participate in any necessary feedback or quality improvement activity;
I will participate in appropriate continuing professional development to obtain and maintain ANSC recognition, as specified in the SWSLHD / SWSPHN ANSC Resource Manual;
I will ensure that SWSPHN has up to date preferred contact information (telephone, facsimile, email, postal address;
I will observe hospital guidelines in respect of mutual patients, including criteria for hospital review/referral;
My Medical Registration is current and without conditions and I will notify the Obstetric Shared Care coordinator if my registration is suspended, cancelled or has restrictions imposed;
My Medical Indemnity/Insurance will be maintained as an adequate level of cover for the duration of my participation of ANSC;
I will keep appropriate clinical records;
When on leave or ill appropriate arrangements be made for continuing care with a recognised Shared Care provider or the participating hospital;
I understand that if I do not follow protocols and attend relevant CPD my recognition status will be withdrawn.

Consent to Release of GP Information*

Consent to Release of GP Information

As part of the ANSC Program, SWSPHN collects GP information (including: name, address, phone, fax, gender, and languages spoken).
This information is forwarded to the Antenatal Clinics to facilitate GP participation in the program.
The National Privacy Principles and the Privacy Act prohibit us from releasing this information without your prior consent.

Signature

My signature below certifies the following:

The information provided by me on this ANSC application form is accurate at the date of submission;
As an ANSC provider, I agree to all the undertakings in Section 6 of this document;
I authorise the SWSPHN ANSC Program to release my personal details, as listed above, to the participating ANSC hospitals.

Name

Date

General Practice Forms

Antenatal Shared Care (ANSC) Program

GP Details

Contact details*

What is your RACGP QA&CPD Number?*

Email content for correspondence*

Contact details

Primary location contact details

Practice address*

Postal address

Postal address

Professional Requirements

Prior Experience Providing Antenatal Care

Professional Referees (medical)

Agreement