Medical Acupuncture Accreditation Application FormI AM A Recognised GP with the HIC (either Fellows List or Vocational Register) p ORI AM A GP Registrar in an approved GP training placement p ORI AM Classified with the HIC as a Rural OMP p ORI AM Other HIC classification (please specify)_________________________________________ I AM PARTICIPATING IN The RACGP QA&CPD Program p The ACRRM PD Program p RACGP / QA&CPD No 5 - - - - - (A 6 digit number beginning with ‘5’ which appears on all RACGP correspondence) (if applicable) ACRRM / PDP No ________________________________________________________________ (if applicable) Provider No _______________________________________________________________E-mail Address _______________________________________________________________Surname _______________________________________________________________Given Names _______________________________________________________________Preferred Mailing Address ________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________ Telephone # _____________________________ Fax # _________________________Are you a member of (Please tick) AMAC p RACGP p ACRRM p AMA p Other p _______________________________ MEDICAL ACUPUNCTURE TRAINING COURSE DETAILSIMPORTANT NOTE: Only those training courses that have been approved by the Joint Acupuncture Working Party, and meet all criteria including the guidelines as set down in the ‘Education Standards Document’ approved by AMAC and the RACGP will be accepted. Please attach a copy of your training certificate with this application as evidence of completion. Name of training course ________________________________________________________ (Attach a copy of your training certificate) (Please refer to the above statement regarding the acceptance of approved training courses only) Who provided the training course________________________________________________________ (Include specific details regarding the course and convenor) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Date training course completed _____________________________________________ FAMAC Pt 1 Date Passed _____________________________________ (please attach evidence) FAMAC Pt 2 Date Passed _____________________________________ (please attach evidence) OTHER Medical Acupuncture Examination ______________________________________ (please specify) Date Passed _____________________________________ (please attach evidence) I certify that I am a Full time (a min of 9-10 GP sessions per week) p Part time (less than 9 but more than 4 GP sessions per week) p General Practitioner who practices Medical Acupuncture Full time (a min of 9-10 MA sessions per week) p Part time (less than 9 but more than 4 MA sessions per week) p Signature including qualifications: ___________________________________ Date: _______________ DECLARATIONI understand that after accreditation my continuing eligibility to claim the higher content based item numbers in Group A1 of the Medicare Benefits Schedule (MBS) in relation to Medical Acupuncture services depends on my continuing to participate in a recognised continuing professional development program and meeting the minimum requirements for Medical Acupuncture each triennium. I understand that the RACGP QA&CPD Program will report to the Health Insurance Commission if I do not meet the minimum Medical Acupuncture requirements each triennium. The information included on this form is subject to Privacy Legislation and will not be used for any other purpose other than reporting on your Medical Acupuncture participation and CPD requirements between the Australian Medical Acupuncture College (AMAC), your preferred CPD provider (either the Royal Australian College of General Practitioners (RACGP) or the Australian College of Rural and Remote Medicine (ACRRM)) and the Health Insurance Commission (HIC). Signature: __________________________________________________Date:________________ PLEASE NOTEYour application should be submitted for assessment with all of the necessary evidence, certificates and documentation to ONE of the Joint Acupuncture Working Party representatives listed below. DO NOT send duplicate or multiple applications, as this will delay your assessment. Dr Daniel J Traum Dr David Mitchell Federal President 2 Hautville Terrace 14 Wildlife Parade NORTH BALWYN VIC 3104 Tele: Fax: (08) 8271 9535 Tel: E-mail: davmitch Fax: E-mail: danjo Dr Paul Coughlan Traralgon Medical Centre 5/11 Kay Street TRARALGON VIC 3844 Tele: Fax: E-mail: paul |