Does any medical practitioner employed or engaged by the Corporate Member Applicant supply after-hours services on weekdays in the period between Sydney Medical Service 1300HOMEGP ceasing to provide services (8.00am) and the opening time of the surgery?

 Yes No

Is the surgery an accredited practice?

 Yes No

Which Primary Health Network does the surgery fall under?

How should patient reports be delivered?

Do you wish to be notified immediately of urgent pathology results or any deaths during the afterhours period?

 Yes No

If yes, Sydney Medical Service 1300HOMEGP will attempt to contact the regular Medical Practitioner of the patient but in circumstances where contact cannot be made, the Principal Representative will be contacted. Please provide a further alternative contact in case the regular Medical Practitioner and Principal Representative cannot be contacted:

(Please note the Principal Representative or alternative nominee may be contacted in unsociable hours when required).

Please note that all information provided by on this Application for Corporate Membership which is not information in the public domain is for use by Sydney Medical Service 1300HOMEGP only and will not be disclosed to any third party except as is required by law.

In accordance with its Rules, notice is given to the Applicant for Corporate Membership that the following documents are available for inspection at Sydney Medical Service’s office at 68 Anderson Avenue, Panania:

• A consolidated copy of its Rules

• Notice of the Subscription fees payable by Members

• Copies of relevant special resolutions passed by the Members, except resolutions providing for an alteration of the Rules

• A copy of the last Annual Report

A Corporate Member shall have one (1) vote only regardless of the number of Medical Practitioners employed or engaged or the number of surgeries. In accordance with the Rules of Sydney Medical Service 1300HOMEGP, that vote may only be exercised by a registered Medical Practitioner. For the purposes of voting and subject to the Rules of Sydney Medical Service 1300HOMEGP, the Principal Representative stated on this form is taken to be the person nominated to exercise the vote on behalf of the Corporate Member.

Sydney Medical Service 1300HOMEGP may distribute notices to Corporate Members by email, fax or post.

Cancellation or resignation of Corporate Membership must be in writing to Sydney Medical Service 1300HOMEGP and will take effect from the commencement of the following quarter.

The information supplied in this Application for Corporate Membership is complete and accurate. You agree to give notice in writing to Sydney Medical Service 1300HOMEGP of any changes to the information supplied in this Application for Corporate Membership as soon as is reasonably practicable.

If any other Medical Practitioner commences at the surgery nominated on this Application for Corporate Membership and wishes to receive the benefits, you will immediately notify Sydney Medical Service of the details of such Medical Practitioner and agree to Sydney Medical Service charging a revised subscription fee based upon the number of Medical Practitioners who shall receive the benefit of the services provided by Sydney Medical Service.

If any Medical Practitioner listed on this Application for Corporate Membership leaves the practice, notice will be given to Sydney Medical Service as soon as reasonably practicable of departure because that Medical Practitioner leaving the nominated practice will no longer be entitled to the benefits of membership of Sydney Medical Service.

Sydney Medical Service will serve notices on the Corporate Members by issuing such notices to the Principal Representative nominated on this Application for Corporate Membership (in accordance with its Rules).

You, and each of the Medical Practitioners listed on this Application for Corporate Membership, are aware of the boundaries and geographic regions presently covered by Sydney Medical Service and understand that:

• patients who reside outside of those boundaries will not be covered for after-hours care by Sydney Medical Service 1300HOMEGP; and

• it is your responsibility and that of the Medical Practitioners listed on this Application for Corporate Membership to make alternative after-hours arrangements for those patients.