First Approved Version: March 6, 2017
Current Approved Version: September 17, 2018
Alternate Practice Arrangement Application
Form Page 1 of 3
APPLICATION TO ESTABLISH AN
ALTERNATE PRACTICE ARRANGEMENT
This form is to be completed by midwives who wish to establish an Alternate Practice
Arrangement (APA). For more information, please refer to the Policy on Alternate Practice
Arrangements.
APA Practice Name:
APA Practice Address:
Anticipated APA Start Date:
APA Practice Website:
Midwife/Midwives Applying and Registration Numbers:
Please submit a proposal with this application including the following required
information in the sections set out below.
Demographic Information
1. The geographic catchment area to be served by your APA.
2. Approximately how many clients/families your APA will serve annually.
3. Available population, provider and demand data relevant to the catchment area.
Standards of Practice Deviations
4. Each proposed deviation from the Standards of Practice, with rationale.
5. A detailed explanation of how care will be delivered in your proposed alternate
practice arrangement and how it will (as applicable):
a) contribute to a high quality of perinatal care in context of proposed exceptions
to Standards of Practice;
b) address a perinatal care need;
c) ensure a high level of client satisfaction;
d) improve access to perinatal care;
e) contribute to health promotion and disease prevention;
