Supporting documentation for applications

The following resources have been developed to assist with:

• providing evidence to support your applications - private hospital or day hospital
• changing details about executive staff or the authority holder.

Supporting documentation

• Accountant's financial statement (DOCX 571 kB)
• Alcohol and other drug services supporting documentation form (DOCX 114 kB)
• Bed and procedural areas form (DOCX 118 kB)
• Clinical services capability framework (CSCF) list of services and levels (DOCX 586 kB)
• Day-to-Day Manager and Nurse In Charge statement (DOCX 127 kB)
• Independent financial statement (DOCX 136 kB)
• Licence to operate supporting documents form (DOCX 133 kB)
• List of Directors, Board Members and Office Bearers (DOCX 118 kB)
• Mental health services supporting documents form (DOCX 118 kB)
• Parent company agreement (DOCX 577 kB)
• Prescribed surgical services form (DOCX 116 kB)
• Prescribed alterations, operational approval supporting documents form (DOCX 123 kB)
• Proposed approval holder (authority holder) consent to release information (DOCX 120 kB)
• Statutory Declaration 2023 (DOCX 283 kB)
• Transfer of a licence supporting documents form (DOCX 126 kB)

Private Health Facility (PHF) standards

• PHF Standards (all) compliance self-assessment tool (DOCX 547 kB)

1. Continuous quality improvement standard self-assessment (DOCX 67 kB)
2. Credentials and clinical privileges standard self-assessment (DOCX 528 kB)
3. Ethics standard self-assessment (DOCX 527 kB)
4. Infection control standard self-assessment (DOCX 528 kB)
5. Information management standard self-assessment (DOCX 529 kB)
6. Management and staffing standard self-assessment (DOCX 529 kB)
7. Minimum patient throughout standard self-assessment (DOCX 527 kB)
8. Patient care standard self-assessment (DOCX 528 kB)
9. Physical environment standard self-assessment (DOCX 528 kB)
10. Patient care standard self-assessment (DOCX 526 kB)

Notifications

• Notification form (PDF 766 kB)

Building certifier referral - concurrency agency

• Referral to the CHO as the concurrency agency (PDF 335 kB)
• QDC_MP5.5 Performance Criteria (XLSX 39 kB)