Expression of Interest Application: Intellectual Disability Primary Care Inclusion Program

This Expression of Interest (EOI) is for the provision of the Intellectual Disability Primary Care Inclusion Program across the Central and Eastern Sydney PHN (CESPHN) region.

The Intellectual Disability Primary Care Inclusion Program aims to enhance, support, and build capacity of primary care providers to effectively care for patients with intellectual disability and assist their families and carers.

The Program offers financial support to general practices to undertake in-practice training and complete Quality Improvement activities related to improving the delivery and accessibility of health care for people with intellectual disability
Applicants must read and understand the following documents prior to completing this application form:

Applications will close 1 February 2024.

Clarification Questions

If you have any questions please email intellectualdisability@cesphn.com.au

Any clarification questions asked by potential applicants will be posted on the CESPHN webpage . Please review answers before continuing your application.

Applicant Details

1. General Practice details

Registered entity name

Trading name of organisation (if different from above)

ABN

Practice contact number

Email address

Website

Street address

Unit / street number / street

Suburb

Postcode

State

Postal address

Leave blank if your postal address is the same as your residential address

Unit / street number / street

Suburb

Postcode

State

3. Bank Account Details

BSB

Financial Institution

Account Number

Account Name

4. Applicant Contact Details

The principal contact person is the person who is legally authorised to enter into contracts on behalf of your organisation. The principal contact person must complete the declaration at the end of this

application and will be required to sign a Memorandum of Agreement for the Provision of Funding if your

application is successful.

Title

Please specify

First name

Surname

Preferred name

Position title

Contact number

Alternative number

Email

Project Contact Person

The project contact person is the person who will be involved in leading the project and maintain contact with CESPHN staff.

Title

Please specify

First name

Surname

Preferred name

Position title

Contact number

Alternative number

Email

Please outline your interest in applying for the Intellectual Disability Primary Care Inclusion program

Declaration

By submitting this form, I hereby agree:

I have read the Central and Eastern Sydney PHN (CESPHN) Intellectual Disability Inclusion Program EOI Guidelines and my practice is eligible to apply.

I declare that all information provided in this application is true and correct.

I acknowledge, understand, and accept that this application does not create a legal or binding commitment, arrangement or understanding between CESPHN and the applicant organisation. Any such commitment, arrangement or understanding will be the subject of further negotiation and documentation, including an agreement for the provision of funding. Additional specific conditions may be included in future agreements.

I acknowledge, understand, and accept that incomplete applications may not be considered.

I acknowledge, understand, and accept that information provided in this application will be stored by CESPHN in various formats including hard copy and/or electronic storage.

Name

Position

Date