GP Antenatal Shared Care (ANSC) Program Application Form

The GP ANSC program is a partnership model of care in which the responsibility of a woman’s antenatal care is shared between an ANSC GP provider and a local public hospital maternity facility.

GPs wanting to register for GP ANSC are required to:

Complete this online application form
Attend an orientation/intake session facilitated by the hospital GP Liaison Midwife and/or relevant staff

Please note: There is an expectation of previous obstetric experience and/or assumed knowledge and skills in caring for low risk pregnant women. The GP ANSC program does not provide formal obstetric training.

CESPHN Privacy Statement

As part of the Antenatal Shared Care Program, CESPHN collects GP information (including GP name, gender, languages spoken and general practice address, phone, fax). This information is forwarded to the antenatal clinics to facilitate GP participation in the program. Additional GP information including mobile phone and email address may be forwarded to hospital GP Liaison Midwife to assist with program participation. The National Privacy Principles and Privacy Act prohibit us from releasing this information without your prior consent which is requested in this form.

CESPHN will manage your data in line with our Privacy Policy, which complies with the Privacy Act 1988 (Cth) and the Health Records and Information Privacy Act 2002 (NSW).

If you have any questions about out privacy policy, please contact CESPHN’s Privacy Officer – info@cesphn.com.au.

GP status

General PractitionerGP Registrar

Royal Hospital for Women (RHW) GP ANSC affiliation is not available for Registrars. However, Registrars in their final year of training may apply and attend an intake session. They will be added to the GP ANSC list at completion of GP training.

Please complete GP ANSC Supervisor details below. This does not need to be your main Supervisor but does need to be a current ANSC GP on the relevant program and a GP that you can readily access to discuss antenatal patients.

Name of GP Supervisor

Email of GP Supervisor

Expected date of training completion

I would like to apply to the following GP Antenatal Shared Care Program(s)

RPA Women and Babies and Canterbury HospitalRoyal Hospital for WomenSt George Hospital and Sutherland Hospital

Contact information

First name

Surname

Role / job title

Mobile phone number (CESPHN use only)

Contact email (CESPHN use only)

RACGP QICPD number

Gender

Prefer to self-describe:

Practice information

If you work at more than one practice, please click "Add another response" below to provide additional practice details.

Practice name

Practice address

Practice suburb

Practice postcode

Practice email address

Practice phone number

Please list any languages, other than English, which you speak fluently and would be willing to use to conduct ANSC consultations:

Are you willing to accept ANSC referrals for patients who do not normally attend your practice?

YesNo

Antenatal Shared Care experience: Please detail previous obstetric experience relating to antenatal care with particular focus on the management of low to medium risk pregnant women.

Please list any other hospitals where you are presently recognised/affiliated to provide antenatal shared care:

AHPRA Medical Registration number:

Please upload a copy of your Medical Indemnity Insurance (PDF)

Are you appropriately indemnified with the right level of cover for GP antenatal shared care?

YesNo

If accepted, I agree to:

1. adhere to the current GP ANSC protocols and policies

2. meet the ongoing GP ANSC educational requirements

3. maintain my APHRA medical registration

4. maintain my medical indemnity insurance

As part of the GP Antenatal Shared Care (ANSC) Program, Central and Eastern Sydney PHN collects GP information (including GP name, gender, languages spoken and general practice name, address, phone, fax). This information is forwarded to the relevant hospital's antenatal clinics to facilitate GP participation in the program. Additional GP information including mobile phone and email address may be forwarded to hospital GP Liaison Midwife to assist with program participation. The National Privacy Principles and the Privacy Act prohibit us from releasing this information without your prior consent. In order to assist us in the process of maintaining your confidentiality, please provide your consent below.

I consent for Central and Eastern Sydney PHN to release my personal details, as listed above, to participating hospitals in order for me to join the GP ANSC Program