Medical Acupuncture Accreditation Application Form

RACGP / QA&CPD No               5   -   -   -   -   -   (A 6 digit number beginning with ‘5' which appears on all RACGP correspondence)

(if applicable)

(if applicable)
Provider No ...............................................................................................................................................................

E-Mail Address..........................................................................................................................................................

Given Names.....................................................................................................................

 

 

Telephone #.....................................................   Fax #.........................................................

Are you a member of (Please tick) AMAC  p        RACGP p       ACRRM p       AMA  p          Other p ..................

MEDICAL ACUPUNCTURE TRAINING COURSE DETAILS
IMPORTANT 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)

Is this training course approved by the Joint Acupuncture Working Party            YES    p                     NO     p

(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)

..........................................................................................................................................................

..........................................................................................................................................................

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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:...........................

DECLARATION

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I 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 NOTE

Your 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 David Mitchell
Federal President
2 Hautville Terrace
Australian Medical Acupuncture College
EASTWOOD SA 5063
Tel:
Fax:
E-mail:  davmitch