Doctor Onboarding (v1)

Doctor Application Form
Psychiatrist Application Form
To complete this application form, you will need to first apply for a provider number with Updoc. This is to ensure that the process is streamlined for you, your patients, and any other doctor that you may refer them to.

Here's some information you may need to apply for a new provider number:

Click here
specialiation
Your Details
Title
invitee_email
Full name

First NameLast Name
Email
example@example.com
Mobile
Please enter your mobile number starting with 04Format: 0400000000.
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Address

Street Address

Street Address Line 2

CityState code (e.g. NSW, WA, VIC)

Zip CodeCountry
Please input a valid state code eg. NSW, QLD, VIC, TAS, WA, SA, NT, or ACT
Registration Details
AHPRA Registration Number
e.g. MED0002017311, NMW0002017311 - 13 characters
I do not currently have any outstanding AHPRA notifications against me
Healthcare Provider Identifier - HPI-I
e.g. 8003618332334219 - 16 characters
Click here to locate your HPI-I
Prescriber number
e.g. 3291592
Provider number
e.g. 6211751H
Please confirm that the provider number above is an Updoc provider number by attaching a screenshot of your PRODA account

Only jpg, jpeg, and png files are supported
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More information on provider number:
- How to apply for an additional provider number
- How to screenshot your PRODA account
Certificate of currency of your existing indemnity insurance - please ensure that you include reference to your Telehealth Consultation coverage.

NOTE: A generic front page of your indemnity cover will not suffice - you must include explicit reference to all areas of coverage, including coverage for private telehealth services in a private clinic.
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Indemnity insurance expiration date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDD/MM/YYYY
I confirm my Professional Indemnity Insurance explicitly covers telehealth. I commit to maintaining this coverage for the duration of our agreement
Please confirm that the provider number above is an updoc provider number
ABN number (with GST registration)
e.g. 14490811802
The ABN provided belongs to Updoc. Kindly enter your own ABN to proceed.
Please confirm the ABN above is registered for GST
Please select the entity type associated with your ABN above
BSB
e.g. 064321
Account number
e.g. 125342501
Please Upload Your Working With Children Check (WWCC)

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Signing Section
I confirm that I have read and understood this application form and the attached Partner Practitioner Agreement.
I confirm that the details and information that I have provided within this application form are true and correct.
By signing here, I understand and agree to be bound by the terms of this Agreement, incorporating the Partner Practitioner Terms and Conditions.
I consent to electronic signature of this Agreement.
Partner Practitioner Signature

Please ensure your signature is legible as it will be used on your clinical document templates, e.g. medical certificates.
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Partner Doctor Referral Program

Were you referred to us by another Partner Doctor on the Updoc platform? If you were, could you please let us know their email address below and we will reach out to them if you are successfully onboarded.
Were you referred to us by another Partner Doctor on the Updoc Platform?
If you were, could you please provide the email address of the doctor who referred you?
eg. john_smith@updoc.com.au
Please input the referring doctor's Updoc email. It should contain "@updoc.com.au".
Relationship to referer
eg. Colleague, University friend, etc.
Thank you! We will reach out to them if you are successfully onboarded.
What specific hours per week are you available to provide services via the platform?
What additional certifications do you have as a doctor?
Please upload a profile photo of yourself similar to the sample with the guidelines below

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Profile photo guidelines

Against a neutral backdrop – ideally beige / white, nothing in the background. You should position yourself about half a metre away from the wall when taking the photo.

Shot with a decent quality camera – if you have a DSLR, this would be perfect, but if you have a high quality phone camera, this should work as well. If you have somebody available to take this image, it’ll help you, but doing a solo shot as well is doable with a timer and something good to rest the phone against / a tripod for your camera!

Lit naturally if you have a wall with some natural light shining in (it can be a relatively flat image as long as your face is fully lit) – otherwise some basic lighting would be valuable too. Nothing too complex – we want to keep this consistent across Doctors!

Shot as a mid shot – essentially the same positioning as the photo included above, ensuring there is a bit of headroom above your head, and the top of your chest area is visible and the photo is taken front on at eye level

Wearing a neutral button up / collared shirt – ideally beige / white, but anything neutral will suffice

Taken in the highest quality format you’re able to – if using a DSLR, this is typically in a RAW format of some kind, and most smartphones will have an option to increase the quality of images to the higher level

Note: if you have an existing photo the fits the above parameters, this will work. Any low quality existing image will NOT work.
Please write out a short blurb about yourself
The inclusion of headshots and small blurbs will help patients feel more secure in their interactions with updoc, and will enable trust building for longer and more positive relationships. Which ultimately means better health outcomes!

A small blurb, including:
- Your relevant health qualifications
- Where you studied
- How long you have been a doctor for
- Where you now work physically
- Your interests within medicine
- Your interests / passions outside of work
Cherish approval
Doctor type
Doctor or Nurse Practitioner?
eRx code
eRx code (Updoc Prescribing Platform)
Rate that has been agreed with practitioner
MC Rate
FOR PAYTON
GC Rate
FOR PAYTON
Who took the sales call with this doctor (this will appear on the success email)
e.g. Luke, Cherish, Adam
Secret Code
In order to continue, please input a valid state code eg. NSW, QLD, VIC, TAS, WA, SA, NT, or ACT in your address
Should be Empty:

Doctor Application Form

Psychiatrist Application Form