GPCanShare Cancer Management Service Application Form

The GPCanShare model is a collaboration between CESPHN and the cancer centres of SLHD, SESLHD and St Vincent's Health Network. It involves shared management of a patient with cancer between the specialist services and general practitioner (GP). GPs will be supported by an integrated nurse coordinator to manage their patient in accordance with their cancer centre care plan.

The below cancer centres are involved in the GPCanShare model:

The Kinghorn Cancer Centre
Concord Repatriation General Hospital
Royal Prince Alfred Hospital
Sydney Local Health District cancer facilities
St George and Sutherland Hospital
Prince of Wales Hospital

GPs wanting to register for the GPCanShare model are required to complete this form. Registered GPs will be contacted by the relevant integrated nurse coordinator to discuss their needs and relevant patient/s.

CESPHN Privacy Statement

As part of the GPCanShare Program, CESPHN collects GP information (including GP name, gender, languages spoken and general practices address, phone, fax). This information is forwarded to the cancer clinic integrated nurse coordinators to facilitate GP participation in the program. Additional HP information including mobile phone and email address may be forwarded to the Integrated GP Nurse Liaison Nurse 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

I am a general practitioner in the Central and Eastern Sydney PHN region

YesNo - please contact Stephanie Walker (GPCanShare Project Officer) at s.walker@cesphn.com.au for more information

Cancer patient status

I have a current patient with cancer or suspected cancer diagnosis

YesNo

Does your patient/s attend one or more of the following cancer centres or would you like to be linked to one of these facilities?

The Kinghorn Cancer CentreConcord Repatriation General HospitalRoyal Prince Alfred HospitalSydney Local Health District cancer facilitiesSt George and Sutherland HospitalPrince of Wales Hospital

Briefly, what would you like to discuss with or seek assistance from the integrated nurse coordinator?

Contact information

First name

Surname

Email address

Mobile phone number

Preferred mode of communication:

EmailPhone

Gender (optional)

Different identity (please specify)

Organisation information

Practice name

Practice address

Practice suburb

Practice postcode

Practice email address

Practice phone number

Additional contact (optional)

We appreciate the demands and availability of GPs so if appropriate please provide details of a practice nurse/manager who is willing to facilitate the link to the integrated nurse coordinator if you are unavailable when contacted.

First name

Surname

Job title

Email address

Mobile phone number

Preferred mode of communication:

EmailPhone

Are you willing to be linked with patients from a cancer centre that do not have a current GP and require one?

YesNo

Please list any languages other than English you speak fluently

As part of the GPCanShare Program Central and Eastern Sydney PHN collects GP information (including GP name, gender, languages spoken and general practice name). This information is forwarded to the relevant hospital's cancer clinics to facilitate in the program.

Additional GP information including mobile phone and email address may be forwarded to cancer centre GP Integrated Nurse Liaison positions 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 cancer centres in order for me to join the GPCanShare Program.

YesNo