Epping Surgery Centre Suite 3, Oxford Place 44-46 Oxford Street, Epping NSW 2121
(02) 9868 6555
Home / Our Doctors / Accreditation Application Form
This form is to be completed in order to apply for an appointment as an accredited practitioner or to apply for re-accreditation.
Please ensure that you fill in all relevant information to the best of your ability. The form should take roughly 20 minutes to fill in fully. There is a save and continue button at the bottom of the screen should you be interrupted.
Before you begin, we advise that you have ready the following documents:
We also advise that you have a copy of the PMA Bylaws open with you as you complete the application.
Please provide details below for three professional references who can attest that your recent practice is consistent with the criteria contained within the PMA Bylaws. The referees provided should be familiar with your current professional capabilities.
Please note that your referees will be contacted and asked to provide a reference. The reference may be verbal or in writing.
Two referees must be from the area of your specialty. One referee must be a senior manager in a hospital or
day procedure facility within which you have worked recently.
Please refer to the PMA Bylaws.
Accredited Practitioners should have insurance cover from an Australian Insurer for $20m in any one claim and
$20m for all claims in the aggregate.
Surgical Assistants should have insurance cover from an Australian Insurer for $10m.
If in doubt, please contact the Facility CEO to discuss.
I confirm that the information contained in this form is true and accurate and is not misleading or deceiving or likely to mislead or deceive.
I understand that if I have provided misleading or deceptive information or information which is likely to mislead or deceive that the Board of the PMA Facility/Facilities at which I am applying to be accredited may (in its absolute discretion) consider that I do not have "Current Fitness"under the PMA Bylaws.
I agree that I will notify the CEO of the PMA Facility/Facilities at which I am accredited of any material changes to the information provided by me in connection with this application as soon as possible after the change.
I understand that my Appointment as an Accredited Practitioner if granted will be reviewed at the end of the current quinquennium or earlier if considered necessary.
I acknowledge that I have been provided with and read a copy of the PMA Bylaws. If appointed, I agree to abide by the PMA Bylaws and policies of the facility at which I am accredited.
I understand that by pressing "Submit," I hereby agree to all the agreements stipulated above.