Application for Membership/Renewal
INTERNATIONAL APPLICATION FOR
DAY HOSPITALS AUSTRALIAMEMBERSHIP 2017-2018
INTERNATIONAL ASSOCIATE MEMBERSHIP (prices quoted below exclude GST):This membership class is available to Day Hospitals or overnight private hospitals under 100 beds that meet the legislative and accreditation requirements for the jurisdiction of the specific country where they are located.
AUD $725.00 full membership year
Joining Fee–AUD $115.00 (one off payment by all new members)
- The Membership Year runs from 1 July to 30 June.
- Day Hospitals must be stand-alone facilities (or, if partially owned by in-patient hospital, then independently managed).
- Day Hospitals or small overnight private hospitals must be appropriately licensed with the associated jurisdiction and accredited by the Government approved body in the specific country where located. A copy of Licensingand Accreditation Certificates are to be provided with this application if applicable in that country.
- International AssociateDay Hospital membership confers the definedprivileges as outlined in Day Hospital Australia’s “Membership Classes and Benefits”table to all employees, owners and directors of the nominated day hospital.
- All International Associate membership applications are subject to Day Hospitals Australia CEO approval before being accepted.
Name of Day Hospital (Trading Name)
Company Name
ABN
Address (Postal) / Street/PO Box
Suburb/Town / State Postcode
COUNTRY
Telephone / Fax:
Primary Contact / Name / Position
Secondary Contact / Name / Position
Ownership: / 1)
2)
1)Is your Day Surgery a standalone facility?
or
2)Does your facility operate within a medical practice? / Yes No
If Yes to question 2 – does it utilise shared staffing?
Yes No
If medical practitioners are owners: / How many? How many are AMA members?
Are you a member of APHA? / Yes No
Please supply name and email address for the following:
OWNER
NameEmail
CEO/DIRECTOR OF NURSING (the person responsible for managing the day hospital)
NameEmail
CHIEF FINANCIAL OFFICER
NameEmail
PRACTICE MANAGER / NURSE MANAGER / BUSINESS MANAGER
NameEmail
OTHER (Position:______
NameEmail
Yourwebsite address:Please indicate if you are in agreement for your day hospital name to appear on our website under List of Members and also within the Find a Member function of the Day Hospital Australia website. This function can link to the Home Page of your facility website (encouraging visitors of the Day Hospitals Australia website to visit your website). Yes No
DETAILS OF DAY HOSPITAL FACILITY – REQUIRED FOR DATABASE
Accreditation Status:
(please tick) / ACHS: / ISO: / OTHER:
(copy of certificate to be provided with this application)
Day Hospital Government assignedRegistration/Provider number:
No of : / Theatres: / Procedure
Rooms: / Beds/ Chairs:
No of Staff: / Nursing: / Admin: / VMO’s:
Specialties Offered:
Year Opened: / Average episodes preformed per annum:
- New members must provide a copy of their Accreditation Certificate and Licensing Certificate with this application form, if applicable in that country.
- We ask that existing members inform Day Hospitals Australia if there has been a change to their current licence or accreditation status
Please indicate if you would like to be a member of any of these Day Hospital Australia Google Groups and supply the relevant email address to be used.
Email: / Management
Ophthalmology
Gastroenterology
National Standards (Australia)
PAYMENT OPTIONS AVAILABLE: PAYMENT MUST BE IN AUSTRALIAN DOLLARS
Cheque:Made payable to:
Day Hospitals Australia Ltd
PO Box 1143
JoondalupDC W.A. 6919 / Direct Payments in to Bank Account:
Account name:Day Hospitals Australia Ltd
BSB:084-004
Account Number:04 957 0987
Please send remittance advice for each payment by email to
Credit Card Payment – (merchant fees apply) AMEX 3% and Visa/MasterCard 1.5%
Please debit my - Visa MasterCard
Expiry: _____/_____CVC (3 digit number on back of card): _____/_____/_____
Name on card:______Signature:______
phone.+61 8 9304 8488 | fax.+61 8 9304 7228 | email. | ABN. 37 054 719 050
website. | mailing address. PO Box 1143, Joondalup DC, WA, 6919