This form is ONLY intended to be used a link from bulk emails or pre-populated QR codes. Some fields vary in format compared to a typical MIPS form to ensure pre-population is possible.
For use in promo logic (steth tags and wardrobe comp)
This field will now only contain external referrers
Completed New Grad Transition form
This is to replace the referring page within the website.
LO initiated?
Date/Time
:  
e5classification
Current member
Application type

Transition to intern membership

Transition to first year dental practice membership

Transition to first year nuclear medicine membership

Use this form to join MIPS or update your membership to free new graduate membership.

Your Details

If the above name details are incorrect please complete the recent graduate form available online.

Date of birth*
Leave blank if unknown

Your healthcare qualifications

NO LONGER USED - Note 27 Aug 2021
Date you commenced your healthcare degree/studies*
Date you completed your healthcare degree/studies*
Employment details*
Date of commencement*

It is an AHPRA registration requirement that healthcare practitioners have appropriate indemnity cover including retroactive cover for their previous practice in Australia. Your retroactive cover date typically reflects the date you commenced providing or studying healthcare in Australia. Retroactive cover ensures that you have continuous cover for claims which you are currently unaware of that might arise from healthcare services provided by you in previous years. If you do not nominate the date you commenced healthcare services or commenced healthcare studies in Australia you will not be provided indemnity by MIPS for any incidents that may arise from those services provided by you prior to your membership start date. Learn more.

Your (likely) primary practice location
Name of your current employer or practice (or future employer if you are yet to commence work).
Supply the number you picked from the barrel (1-23)

Practice information

As you are currently awaiting a job offer, please estimate the following practice information. You can update MIPS once you have commenced practice if the estimates are inaccurate.

All healthcare practice
Type of healthcare practice undertaken*
If you are an employee with a salary, your position may be 'Employer indemnified only', however, you should check your employment contract. If you are yet to commence practice, answer this section with how you expect to be practising once you commence.
% of total healthcare practice (hours)

Indemnity & personal history

Have you ever had indemnity insurance cover or membership of a Medical Defence Organisation (MDO) declined, rejected, refused or cancelled?*
Have you ever had an excess, risk surcharge, special condition, non-standard exclusion or practice restriction placed on your indemnity insurance cover or membership of a MDO?*
Have you ever had assistance withdrawn or refused for any complaint, claim or circumstance related to your healthcare activities?*
Have you ever been charged with or convicted of a criminal offence?*
Disregard traffic/minor motor vehicle licensing offences
Are you aware of any claims, circumstances, legal actions, suits, investigations, complaints or like, either threatened or actual, made against you currently or in the past?*
Are you aware of any previously unreported incidents or circumstances from your healthcare activities that could lead to a complaint, claim or legal action?*
Has your AHPRA registration ever been revoked, suspended or had conditions applied to it or has there ever been a matter brought before a registration board?*
Attach any additional information appropriate for your application
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Attach claims history (letter of good standing)
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Attach second document
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Upload another file?
Attach third document
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Upload another file?
Attach fourth document
No File Chosen
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Important information

Would you like to add any additional information?*

Every membership of the Medical Indemnity Protection Society is based upon the terms and conditions of its Constitution, as amended from time to time. 

You can download a copy of the MIPS Member Handbook combined PDS and FSG from the MIPS website at anytime.

New graduate membership is free

Fees for new graduate members are waived from graduation until the following 30 June and may be waived as a recent graduate beyond this. If a membership fee applies MIPS will send written notice before you commit to membership or renewal of membership.

By using this form you are updating to free new graduate membership, but if in the future any membership fee or other liability to MIPS is in arrears for more than one month, you shall then cease to be entitled to any benefits of membership from MIPS from the date when such membership fee or other liability fell due. MIPS may, by resolution, cancel my membership if I do not comply with MIPS’ Constitution, or if my conduct should be deemed to be prejudicial to the interests of MIPS.

Duty of disclosure

You should read and understand your duty of disclosure and ensure that the information you provide is accurate. If during the period of your membership, your circumstances change and the information you provided to MIPS is no longer accurate, you must promptly inform MIPS of the new information.

Permission to provide information

By completing this form, you authorise MIPS to obtain claims and any other information it requires from your previous Insurers/Indemnifiers to confirm the information you have provided. You also consent to MIPS providing my personal information to its agents, legal representatives and other service providers who may need access to your personal information in order to process your application for insurance cover and who may be engaged in the defence of any claim made by you.

Privacy

The information requested in this form is required by MIPS for its business operations. By completing this form you consent to the collection, use, storage and disclosure of any personal information as outlined in our Privacy Statement. These policies are consistent with the requirements of the Privacy Act and Australian Privacy Principles.

Use this form to update your membership classification to free new graduate membership. 

By completing this form you acknowledge that you have read and understood your duty of disclosure and that the information you have provided is accurate. If during the period of your membership, your circumstances change and the information that you have provided to MIPS is no longer accurate, you must promptly inform MIPS of the new information.

You can download a copy of the MIPS Member Handbook combined PDS and FSG from the MIPS website at anytime.

Privacy

The information requested in this form is required by MIPS for its business operations. By completing this form you consent to the collection, use, storage and disclosure of any personal information as outlined in our Privacy Statement. These policies are consistent with the requirements of the Privacy Act and Australian Privacy Principles.

ADMIN Year 0
This is a hidden field used to create the Year of submission in conjunction with the Year calculation
This is a hidden field used to create the Year of submission in conjunction with Year 0
This is a hidden field to create a value of the Year of submission. This is used in the Google Sheets spreadsheet for the LO reporting
Progress
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