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Rural Other Medical Practitioners (Romps) Programme Registration Form - Australian Department Of Health Page 4

Rural Other Medical Practitioners (ROMPS) Programme Registration Form

6. Expression of Interest (Please tick box)

This section must be completed in order for you to be considered for the Programme.

I express an interest in undertaking a pathway to the

Fellowship of the Royal Australian College of General

Practitioners (FRACGP) or Fellowship of the Australian

☐

College of Rural and Remote Medicine (FACRRM).

Please note: It is a requirement of the ROMPs Programme

that applicants express an interest in undertaking FRACGP

or FACRRM. You may be contacted to verify your

enrolment in one of these Programmes.

7. Declaration

1) The information that I have supplied in this Application Form is true and correct in every

particular.

I understand that providing false and misleading information is a serious offence.

I consent to the release and exchange of such information between any two or more of the

Department of Health, the Department of Veterans’ Affairs, Medicare Australia, the Royal

Australian College of General Practitioners and the Australian College of Rural and Remote

Medicine for the purposes of administering, monitoring, reviewing and evaluating the

Programme.

Signature:

Date:

Please send the completed form and any relevant information to:

Medicare Australia

Provider Eligibility Section

GPO BOX 9822

ADELAIDE SA 5001

By email to:

PROVIDER.REGISTRATION@humanservices.gov.au

Further enquiries can be made to Medicare Australia Adelaide on 1800 032 259.

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Rural Other Medical Practitioners (Romps) Programme Registration Form - Australian Department Of Health Page 4