Practice Information Form

Practice Information Form

Department of Health and Wellness (DHW) approval is required for recruitment to all family practice vacancies. This includes new positions, replacement positions and locum terms over 90 days.The approval process for the Central Zone is coordinated through the Department of Family Practice (DFP) for Halifax, Eastern Shore & West Hants.

Please complete the following and return to the Department of Family Practice (or fax 902.454.7107) to initiate the approval process.

1.Requested position:

Permanent Position

a.Position type:

New Position

Rationale for new position ______

______

Replacement Position

Departing Physician______

Departure Date______

Full Time / Part Time______

Reason for Leaving ______

b.What is the range and volume of services provided by the new physician? If this is a replacement position, please indicate any change in service being provided.

______

______

______

Locum PositionTerm ______

2.Do you have a physician that you plan to recruit?

Yes

No

If yes,

Replacement Physician______

Anticipated start Date______

3.Please list names of other physicians at the practice, number of days (or half days, evenings) worked per week, and type of practice (for example, full family practice, walk-in, specialist care):

Physician / Type of Practice / Hours worked per week

4. Does this position provide after hours (evening and/or weekends) access?

Yes

No

Which days and times is after-hours/weekend access offered at the practice?

______

______

5.Does this position:

network with providers/teams in other communities?

provide/receive outreach services?

 work with an interdisciplinary team?

Please list any non-physician health professionals and services provided at the practice (for example, nurse practitioner, family practice nurse, dietitian).

Physician / Services provided / Hours worked per week

6.Are any members of the practice currently accepting new patients?

______

______

If any members of the practice are accepting new patients, please note any specific conditions required for accepting patients into the practice (for example, prenatal care only; local area only; only patients who do not currently have a family doctor).

______

______

If approved, would the physician in the new position be expected to accept new patients?

______

______

7. Is the practice on an EMR?

YesName of EMR ______

No, with no immediate plan to convert to an EMR

No, with a plan to convert to an EMR by (approximate date) ______

8.What is the estimated practice size?

______

______

9.Please provide any details on the practice population and community which would support having the position approved.

______

______

______

______

______

______

10.This position will be posted with a note, pending DHW approval on the Department of Family Practice website. If this position is approved, we recommend contacting Doctors Nova Scotia to post the position on the DNS webpage.

Please indicate if you do not want the position posted on the Department of Family Practice website.  No – do not post position on DFP website.

If you would like the position posted on the DFP website, please provide details of the posting:

______

______

______

Contact name______

Practice Name______

Phone number ______

Email address ______

Closing date______

Postings will be added to the website ()within 7 business days and removed after 60 days unless a closing date is specified.