Area of Need Application Form

FOR FURTHER INFORMATION ON AREA OF NEED ENDORSEMENTS, PLEASE VISIT:

https://www2.health.vic.gov.au/health-workforce/working-in-health/international-health-professional-victoria/area-of-need-reqs-intl-medical-graduates

Endorsement Type *

Applicant Details

Applicant

Title *

First Name *

Surname *

Applicant Phone *

Applicant Email *

Applicant Organisation *

Applicant Address

Street address *Street address line 2

City *

State *

Postcode *

Position Details

Employing Organisation *

Position Type *

Speciality *

Statement of Need *

All applications must include a statement of need outlining why the employer needs to employ an international medical graduate. Statements may include information on the number of recruitment attempts, geographical pressures, and special cultural needs relevant to the demographic.

AHPRA Registration

Please attach a copy of the doctor's current medical registration from the AHPRA Registers of Practitioners

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Important Information

From 1 July 2019, International Medical Graduates who are General Practitioners need to work in a Distribution Priority Area (DPA) to access Medicare under section 19AB of Australia's Health Insurance Act 1973. Non-GP specialists subject to Section 19AB of Australia’s Health Insurance Act 1973 may need to work in a District of Workforce Shortage to access Medicare.

For further information on changes to District of Workforce Shortage policy and methodology, please visit the Australian Government's DoctorConnect website.

I have read and understand the contents of the Australian Government's DoctorConnect website. *

For information on section 19AB of the Health Insurance Act 1973, please visit the Australian Government's Section 19AB webpage.

I have read and understand the Section 19AB of the Health Insurance Act 1973 requirements. *

International Medical Graduate (IMG) DETAILS

For information on Section 19AA of the Health Insurance Act 1973, please visit the Australian Government's Section 19AA webpage.

IMG details must accord with the AHPRA Register of Practitioners, where applicable. All middle names should be included in the 'IMG given name(s)' field. Applications will not be accepted where the details differ from the AHPRA Register of Practitioners.

IMG Given name(s) *

IMG surname *

IMG Residency Status *

Permanent Resident

I understand and acknowledge that general practitioners who are permanent residents or citizens who are not enrolled in a recognised training program or do not hold vocational recognition may be subject to section 19AA of the Health Insurance Act 1973. *

Employer/Authorised Agent Declaration

Please note: New applications for an Area of Need endorsement should be authorised by the employing health service or medical practice or the employer's authorised agent (e.g., practice manager, director of medical services, recruitment agency or RWAV).

The following details are the same as for the applicant. *

Employer/authorised agent First name *

Employer/authorised agent Surname *

Employer/authorised agent Email *

Employer/authorised agent Phone no. *

Employer/authorised agent Position *

I hereby request an Area of Need determination as detailed herein, on the basis that there are insufficient medical practitioners in the nominated location to provide a service at a level that meets the needs of people living in that/those location/s. This request is made with the understanding that the doctor identified will need to successfully secure registration with the Medical Board of Australia and that approval of an Area of Need does not guarantee access to the Medicare Billing arrangements. *

Employer/authorised agent Address

Street address

City

State

Postcode

Primary Location

Primary Location Name *

Primary Location Address *

Street address *

City *

State *

Postcode *

Distribution Priority Area (Primary Location) *

Evidence for DPA location attached (Primary Location) *

Attach your file/s (DPA Primary location)

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District of Workforce Shortage (Primary Location) *

Evidence for DWS location is attached (Primary Location) *

Attach your file/s (DWS Primary location)

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Indicate which 19AB exemption category applies (non DPA and DWS Primary location)Only required for Non-DPA/DWS Applications.

Attach your file/s (non DPA and DWS Primary location)

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Second Location

Is there a second location *

YesNo

Second Location Name *

Second Location Address *

Street address *

City *

State *

Postcode *

Distribution Priority Area (Second Location) *

Evidence for DPA location attached (Second Location) *

Attach your file/s (DPA Second location)

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District of Workforce Shortage (Second Location) *

Evidence for DWS location is attached (Second Location) *

Attach your file/s (DWS Second location)

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Indicate which 19AB exemption category applies (non DPA and DWS Second location)Only required for Non-DPA/DWS Applications.

Attach your file/s (non DPA and DWS Second location)

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Third Location

Is there a Third Location *

YesNo

Third Location Name *

Third Location Address *

Street address *

City *

State *

Postcode *

Distribution Priority Area (Third Location) *

Evidence for DPA location attached (Third Location) *

Attach your file/s (DPA Third location)

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District of Workforce Shortage (Third Location) *

Evidence for DWS location is attached (Third Location) *

Attach your file/s (DWS Third location)

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Indicate which 19AB exemption category applies (non DPA and DWS Third location)Only required for Non-DPA/DWS Applications.

Attach your file/s (non DPA and DWS Third location)

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Fourth Location

Is there a Fourth Location *

YesNo

Fourth Location Name *

Fourth Location Address *

Street address *

City *

State *

Postcode *

Distribution Priority Area (Fourth Location) *

Evidence for DPA location attached (Fourth Location) *

Attach your file/s (DPA Fourth location)

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District of Workforce Shortage (Fourth Location) *

Evidence for DWS location is attached (Fourth Location) *

Attach your file/s (DWS Fourth location)

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Indicate which 19AB exemption category applies (non DPA and DWS Fourth location)Only required for Non-DPA/DWS Applications.

Attach your file/s (non DPA and DWS Fourth location)

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Fifth Location

Is there a Fifth Location *

YesNo

Fifth Location Name *

Fifth Location Address *

Street address *

City *

State *

Postcode *

Distribution Priority Area (Fifth Location) *

Evidence for DPA location attached (Fifth Location) *

Attach your file/s (DPA Fifth location)

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District of Workforce Shortage (Fifth Location) *

Evidence for DWS location is attached (Fifth Location) *

Attach your file/s (DWS Fifth location)

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Indicate which 19AB exemption category applies (non DPA and DWS Fifth location)Only required for Non-DPA/DWS Applications.

Attach your file/s (non DPA and DWS Fifth location)

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Sixth Location

Is there a Sixth Location *

YesNo

Sixth Location Name *

Sixth Location Address *

Street address *

City *

State *

Postcode *

Distribution Priority Area (Sixth Location) *

Evidence for DPA location attached (Sixth Location) *

Attach your file/s (DPA Sixth location)

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District of Workforce Shortage (Sixth Location) *

Evidence for DWS location is attached (Sixth Location) *

Attach your file/s (DWS Sixth location)

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Indicate which 19AB exemption category applies (non DPA and DWS Sixth location)Only required for Non-DPA/DWS Applications.

Attach your file/s (non DPA and DWS Sixth location)

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Seventh Location

Is there a Seventh Location *

YesNo

Seventh Location Name *

Seventh Location Address *

Street address *

City *

State *

Postcode *

Distribution Priority Area (Seventh Location) *

Evidence for DPA location attached (Seventh Location) *

Attach your file/s (DPA Seventh location)

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District of Workforce Shortage (Seventh Location) *

Evidence for DWS location is attached (Seventh Location) *

Attach your file/s (DWS Seventh location)

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Indicate which 19AB exemption category applies (non DPA and DWS Seventh location)Only required for Non-DPA/DWS Applications.

Attach your file/s (non DPA and DWS Seventh location)

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Eighth Location

Is there a Eighth Location *

YesNo

Eighth Location Name *

Eighth Location Address *

Street address *

City *

State *

Postcode *

Distribution Priority Area (Eighth Location) *

Evidence for DPA location attached (Eighth Location) *

Attach your file/s (DPA Eighth location)

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District of Workforce Shortage (Eighth Location) *

Evidence for DWS location is attached (Eighth Location) *

Attach your file/s (DWS Eighth location)

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Indicate which 19AB exemption category applies (non DPA and DWS Eighth location)Only required for Non-DPA/DWS Applications.

Attach your file/s (non DPA and DWS Eighth location)

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Ninth Location

Is there a Ninth Location *

YesNo

Ninth Location Name *

Ninth Location Address *

Street address *

City *

State *

Postcode *

Distribution Priority Area (Ninth Location) *

Evidence for DPA location attached (Ninth Location) *

Attach your file/s (DPA Ninth location)

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District of Workforce Shortage (Ninth Location) *

Evidence for DWS location is attached (Ninth Location) *

Attach your file/s (DWS Ninth location)

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Indicate which 19AB exemption category applies (non DPA and DWS Ninth location)Only required for Non-DPA/DWS Applications.

Attach your file/s (non DPA and DWS Ninth location)

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Tenth Location

Is there a Tenth Location *

YesNo

Tenth Location Name *

Tenth Location Address *

Street address *

City *

State *

Postcode *

Distribution Priority Area (Tenth Location) *

Evidence for DPA location attached (Tenth Location) *

Attach your file/s (DPA Tenth location)

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District of Workforce Shortage (Tenth Location) *

Evidence for DWS location is attached (Tenth Location) *

Attach your file/s (DWS Tenth location)

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Indicate which 19AB exemption category applies (non DPA and DWS Tenth location)Only required for Non-DPA/DWS Applications.

Attach your file/s (non DPA and DWS Tenth location)

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Please ensure all information within this form is correct prior to submission.

I have checked that the information presented in this form is correct. *

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