Application Form

General Practice After Hours Grants Program 2025 - Enhanced After Hours Supports (Stream 1)

The grant program is available to General Practices and Aboriginal Medical Services (within the WNSW PHN region ) to undertake initiatives aimed at enhancing their after-hours service capacity and capability.

Applications will remain open until 5:00pm, Friday 20 June 2025.

Applicants are required to read the Application Guidance before applying. Submission of a signed online application does not guarantee funding. WNSW PHN reserves the right to request changes to the proposed activity prior to approval.

Funding of up to $25,000 (excluding GST) will be made available per application.

APPLICATION DETAILS

Legal Name of Organisation: *

Trading Name of Applicant (if applicable):

Do you have an ABN? *

Yes No

ABN: *

Are you registered for GST? *

YesNo

If Other, please specify *

Street address *Street address line 2

City *

State *

Postcode *

Briefly describe your organisation (no more than one paragraph) *

APPLICATION CONTACT DETAILS

In this section you are asked to provide contact details of your organisation's authorising officer and/or key contact person for this application. The authorised contact person is the person who is authorised to sign a funding agreement on behalf of your organisation, should your application be successful.

Authorised Person’s name: *

Authorised Person's Position title: *

Authorised Person's Email Address *

The application contact should be the person we will contact for any issues related to the application and project activity:

Application contact person: *

Application contact person position title: *

Contact Person's Email Address *

Contact Person's Phone number: *

ELIGIBILITY CRITERIA

General Practice or Aboriginal Medical Service operating within the WNSW PHN region *

YesNo

Are you registered for and do you consent to share information via the Lumos Program (or are you prepared to participate) *

YesNoNot applicable – applicant is an Aboriginal Medical Service

Registered with, and publish information via, Provider Connect Australia. *

YesNo

Actively using My Health Record General. *

YesNo

Practitioners are capable of electronic prescribing. *

YesNo

Actively using secure messaging for clinical communication. *

YesNo

Have access to a video consultation platform that meets security and safety standards for telehealth. *

YesNo

Holds Public Liability Insurance (minimum coverage $10 million) *

YesNo

Holds Professional Indemnity Insurance *

YesNo

Details of Proposed Activities

Describe your current after hours services (Include hours, staffing, service types delivered) *

Proposed activity or service model (Outline what you are proposing to do with this funding) *

How will the proposal address community needs in the after hours period? (Especially in relation to access gaps, workforce, or service availability) *

Expected benefits or outcomes (e.g., reduced ED presentations, improved access, client satisfaction) *

ACTIVITY BUDGET

Please provide a breakdown on how you intend to utilise the funds.

Expense Type *

Description of expenses *

Budgeted Amount (excl GST) *

Total Amount Budgeted $ (excl GST) *

DECLARATION

This section must be completed by an authorised representative of the organisation submitting the application.

I declare that:

I confirm the contents of this application are to the best of my knowledge accurate, complete and do not contain any false, misleading, or deceptive misrepresentation, claims or statements. *

I have read, understood, and agree to the Grant Guidelines, should this application be successful. *

I declare that the organisation is financially viable and able to manage the funding within the timeframe and within budget. *

I understand that the evaluation decision is final, and no correspondence will be entered into. *

I understand and accept that information provided in this application will be stored by WNSW PHN in various formats, including hard copy and or electronic. *

I confirm that this application does not duplicate existing funding, service delivery or ongoing operational costs. *

I agree to contact WNSW PHN should I become aware of any changes to information contained in this application. *

I understand that this application does not create a legal or binding commitment. *

If the application is successful, I acknowledge that:
- The organisation will be asked to sign a Grant Agreement with the WNSW PHN;
- The organisation will be asked to sign a statement stating they have used the funds in accordance with their application;
- The organisation will provide reports to the WNSW PHN in accordance with their grant agreement; and
- The organisation agrees to maintain adequate insurance for the duration of this grant agreement and provide WNSW PHN with proof when requested. *

I understand if the conditions of the funding are not complied with:
- The WNSW PHN will recover the funds allocated; and
- The WNSW PHN may terminate the grant agreement with the applicant. *

I have read the WNSW PHN General Grant Conditions *

Applicant Signature *

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Name *

Position *

Date: *

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