Does any applicant for joint membership 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 your surgery?

 Yes No

Is the surgery an accredited practice?

 Yes No

In which Medicare Local Division is the surgery located?

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 Applicants for Joint 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

Joint Members shall have one (1) vote between them which may only be exercised by the Principal Representative (subject to the valid appointment of an attorney).

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

Cancellation or resignation of Joint 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 Joint 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 Joint Membership as soon as is reasonably practicable.

If this Application for Joint Membership is accepted, all applicants named in the application will be admitted as a Joint Members of Sydney Medical Service 1300HOMEGP. Each Joint Member will:

• be bound by the Rules of Sydney Medical Service 1300HOMEGP; and

• be entitled to the benefits of membership of Sydney Medical Service 1300HOMEGP (subject to the Rules of Sydney Medical Service 1300HOMEGP)

If any other Medical Practitioner commences at the practice nominated on this Application for Joint Membership and wishes to receive the benefits, you will immediately notify Sydney Medical Service 1300HOMEGP of the details of such Medical Practitioner and agree to Sydney Medical Service 1300HOMEGP 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 1300HOMEGP.

If any Medical Practitioner admitted as a Joint Member leaves the practice, notice will be given to Sydney Medical Service as soon as reasonably practicable of departure because a Joint Member leaving the nominated practice will no longer be entitled to the benefits of membership of Sydney Medical Service 1300HOMEGP.

Sydney Medical Service 1300HOMEGP will serve notices on Joint Members by issuing such notices to the Principal Representative only on behalf of all Joint Members (in accordance with its Rules).

You, and each of the applicants for Joint Membership, are aware of the boundaries and geographic regions presently covered by Sydney Medical Service 1300HOMEGP 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 each applicant for Joint Membership to make alternative after-hours arrangements for those patients.