MercyAscot

Dear Specialist,

With all of the ups and downs that this year brought, one thing has stood out clearly - that the strength of our relationships are of the utmost importance. We are a team. So, with that in mind I’d like to take a moment to thank you for your continued partnership and commitment to us.

On Friday 27th November, we emailed you regarding recredentialing. Thank you to those that filled in your forms, and thank you to those that gave us some feedback regarding our wording. We have updated some of our wording accordingly. We have simplified and clarified the wording for the Disclosures, Declaration and Acknowledgement sections.

For those of you who had already submitted, the current and updated wording in this form applies to you. However, if you prefer to re-submit with the current wording then please do so by clicking the link below. We will delete your initial submission in favour of your latest one.

As one of MercyAscot’s valued credentialed specialists we require your details to be annually updated in order to maintain your credentialed status with us.

This year we’ll ask you to fill in an online form and upload information. To make things a little easier we’re giving you the option of uploading your documents as photos, if you are using a smartphone or tablet. If you are using a desktop computer you will be able to upload PDFs, as usual.

Before you complete the form you will need ensure that you have updated copies available, as photos or PDFs, of your:

Indemnity Insurance, and
Continuing Professional Development certificate.

You will need to attach evidence of your Continuing Professional Development Programme and Indemnity Insurance. This evidence has to be current at the time of submission. We acknowledge that for some of you this will involve documents that are due to expire in the near future.

We’d ask that you please complete your form by Wednesday 16th December. We appreciate that this is a short turnaround, so we have designed a simple process with only a few easy steps needed to submit.

We understand that some doctors will be unable to complete the form by this date. Please be assured that this will not impact your credentialing with us and you will continue to be able to practice at MercyAscot. However, we will be sending email reminders out to complete the process as soon as possible.

If you have any questions or encounter problems completing this form, please email diane.reynolds@mercyascot.co.nz and she can support you to complete this via email.

Regards,
Dr Manoj Patel
Director of Medical Services
MercyAscot Hospitals

First name

Last name

Email address

New Zealand Medical Council Registration #

Have you satisfied, or are you completing your College’s Continuing Professional Development Programme?

Yes

Please attach a copy of your Statement of Re-certification or current statement.

When is your indemnity insurance due to expire? Format: dd/mm/yyyy

Please attach a copy of your certificate showing current indemnity insurance.

Do you have regular or overnight contact with children (up to 18 years of age)? (Under the Children’s Act, ‘regular’ is defined as, at least once a week or at least four days each month or overnight. ‘Contact’ is defined as physical contact, or any communication whether oral or electronic or any other means, including by way of writing or visual images.)

Yes

Disclosures

The 2017 Bylaws require specialists to disclose the following to MercyAscot where:

Any physical or mental condition, or substance abuse issue, arises that has the potential to affect the Specialist’s ability to practise or that may require any special assistance to enable him or her to practise safely;
Any proceeding, investigation or formal complaint is commenced in relation to the Specialist by the Medical Council of New Zealand, Specialist’s College, Health and Disability Commissioner, Privacy Commissioner, Coroner, Police, Ministry of Health, the Specialist’s employer or any hospital or any other place or organisation where the Specialist does or has practised;
The Specialist’s appointment, credentialing status or scope of practice at any other hospital or any other place where the Specialist does or has practised are altered in any way, including if withdrawn to any degree, suspended, restricted and/or made conditional and whether by way of agreement or otherwise; or
The Specialist is charged with a criminal offence.

Do you have anything to disclose in the period since you last completed an annual credentialing update at MercyAscot? (MercyAscot last undertook an annual credentialing update commencing 10th July 2019).

If your answer is ‘yes’, please tick this box and provide details. If your answer is ‘no’ click ‘Next’.

Declaration and acknowledgement

I declare that:

the information contained on this form is accurate and complete.
I am competent and trained to perform in the specialty and sub-specialty (if any) that I am currently practising in at MercyAscot.

I understand that the truth and completeness of the information provided by me is essential to and will be relied upon by MercyAscot and if I have falsified or withheld any information, this may be grounds for the immediate termination of my credentialed status.

If you have any questions please contact Diane Reynolds (diane.reynolds@mercyascot.co.nz).

Name

Date

Thank you

Your form has been submitted to MercyAscot.

If you have any questions please contact Diane Reynolds (diane.reynolds@mercyascot.co.nz).