Expression of Interest Application: Intellectual Disability Primary Care Inclusion Program

This Expression of Interest (EOI) is for general practices to participate in the Intellectual Disability Primary Care Inclusion Program across the Central and Eastern Sydney PHN (CESPHN) region.

The Intellectual Disability Primary Care Inclusion Program aims to enhance, support, and build capacity of primary care providers to effectively care for patients with intellectual disability and assist their families and carers.

This Program offers financial support to general practices undertaking quality improvement activities and in-practice training to improve the delivery and accessibility of health care for people with intellectual disability.

Please ensure you have read the following documentation before applying:

- EOI Guidelines
- Memorandum of Agreement

For further information, please see the CESPHN website.

Applications will close Wednesday 25th April 2025.

If you have any questions, please email intellectualdisability@cesphn.com.au

Applicant Details

1. General Practice details

Registered entity name

Trading name of organisation (if different from above)

ABN

Practice contact number

Email address

Website

2. Street Address

Street

City

State

Postcode

Postal Address

Leave blank if your postal address is the same as your residential address

Street

City

State

Postcode

3. Applicant Contact Details

The principal contact person is the person who is legally authorised to enter into contracts on behalf of your organisation. The principal contact person must complete the declaration at the end of this

application and will be required to sign a Memorandum of Agreement for the Provision of Funding if your

application is successful.

Title

Please specify

First name

Surname

Preferred name

Position title

Contact number

Alternative number

Project Contact Person

The project contact person is the person who will be involved in leading the project and maintain contact with CESPHN staff.

Title

Please specify

First name

Surname

Preferred name

Position title

Contact number

Alternative number

Please outline your interest in applying for the Intellectual Disability Primary Care Inclusion program

Declaration

By submitting this form, I hereby agree:

I have read the Central and Eastern Sydney PHN (CESPHN) Intellectual Disability Inclusion Program EOI Guidelines and my practice is eligible to apply.

I declare that all information provided in this application is true and correct.

I acknowledge, understand, and accept that this application does not create a legal or binding commitment, arrangement or understanding between CESPHN and the applicant organisation. Any such commitment, arrangement or understanding will be the subject of further negotiation and documentation, including an agreement for the provision of funding. Additional specific conditions may be included in future agreements.

I acknowledge, understand, and accept that incomplete applications may not be considered.

I acknowledge, understand, and accept that information provided in this application will be stored by CESPHN in various formats including hard copy and/or electronic storage.

Name

Position

Date