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Filing a Complaint 1. Complete this form with (College of Physicians & Surgeons of Alberta)

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Send completed form to:
Professional Conduct Department
College of Physicians & Surgeons of Alberta
2700-10020 100 ST NW
Edmonton, AB T5J 0N3
Questions/Need Help?
Visit cpsa.ca or contact a Patient
Advocate at 1-800-661-4689
(toll-free in Canada)
Also, see the back side of this page for
how a Patient Advocate can help.
Instructions:
1. Complete this form with as much detail as possible. (Please type or print.)
2. Sign and date the form.
3. Attach any additional documents to support the complaint. (Patient records, proof of
authority, etc.)
4. Mail the completed original form to us. (We cannot accept electronic copies.)
When we receive your form, we will:
9 Review all information received. Further communication with the parties involved may occur.
9 Send a copy of your completed form to the physician(s) listed to obtain a response, as
necessary.
9 Contact other individuals and institutions named in your complaint form who may have
information relevant to your complaint. They may receive a copy of your complaint form.
9 Provide you with a written response. The physician(s) will also receive a copy.
What we CANNOT do:
2 Give a diagnosis, treatment recommendation, referral, or direct patient care.
2 Oer or inuence nancial compensation.
2 Help you with concerns or complaints about a health professional who is not an Alberta
physician or surgeon. (Please direct such concerns to the appropriate organization or
regulatory authority.)
2 Resolve complaints without contacting the physician(s) identied.
2 Oer legal advice.
Filing a Complaint
My Checklist
Ensure you include the following:
Name & address of the physician(s)
involved
Detailed description of the complaint
Documents that support the
complaint (if applicable)
Contact information so we can reach
you
Completed & signed Complaint form
Signed & dated Consent form
Proof of authority, if you are not the
patient (see Patient Details section)
P
Complaints/Complaint Submission
*Due to COVID-19 and the need to reduce
contact, we are currently accepting signed
and completed complaint forms by email:
complaints@cpsa.ab.ca and fax: 780.424.9617
BEFORE you submit a complaint, we’ll:
9 Listen to understand your concerns
9 Discuss options for you to resolve your concern
9 Explain CPSA’s complaints process and how to submit a complaint
9 Provide you with forms, if necessary
AFTER you submit a complaint, we’ll:
9 Contact you to clarify any unclear issues or expectations in your complaint
so the Complaints Director can direct it appropriately
9 Attend any required meetings and provide you with support, when needed
9 Answer any questions you have while going through the complaints process
9 Help you understand the nal decision letter and any next steps
1. Will the physician know I’m making a complaint?
Yes. When we notify the physician that we received a complaint, we give them a copy of your
written complaint/complaint submission to review and if required, respond.
2. What is reviewed during an investigation?
We may collect medical records and interview any individuals who may have relevant information
about your complaint.
3. Can I be sued for ling a complaint?
No. However, if you distribute copies of the complaint to others, that may be considered libel and
may put you at risk legally.
4. Will I be nancially compensated if my complaint is upheld?
No. If you are looking for nancial compensation you should obtain legal advice.
5. How long does the complaints process take?
We strive to resolve complaints in a timely manner. However, reviewing a complaint can take
several months or years, depending on the complaint’s complexity, length of investigation and
availability of experts (if required).
6. What are possible outcomes of a complaint investigation?
• The complaint may be dismissed if evidence does not support the complaint or there was
insucient evidence to proceed.
• We may work with the physician to make necessary practice changes. This requires consent
from the complainant.
• The complaint may go to a formal hearing, which may result in discipline.
Contact a Patient Advocate - we can help!
Email: complaints@cpsa.ab.ca
Phone: 1-800-661-4689 (in Canada)
Monday to Friday, 8:15 AM – 4:15 PM (MST)
1
2
FAQs
I am NOT the patient. I am the patient’s
Please provide the following patient information:
Ms./Mrs./Mr./Dr./Etc.
First Name Last Name
Address City Postal Code
Home Phone # Cell Phone #
Birthdate (day/month/year) AB Health Care #
If applicable, date of death (day/month/year)
If you are ling this complaint on behalf of someone else, you may need to
submit proof of your authority.
Documentation you are including as proof of authority:
Patient’s signature on form Will Guardianship Order Other None
For more information about authority, please contact a
Patient Advocate at 1-800-661-4689 (in Canada).
B)
Ms./Mrs./Mr./Dr./Etc.
First Name Last Name
Address City Postal Code
Home Phone # Cell Phone #
Email I agree to receive emails about this complaint
1. Your contact information:
I am the patient (see contact information above)
Birthdate
(day/month/year)
AB Health Care #
A)
2. Patient details:
Complete section A) if you are the patient or section B) if you are not the patient
COMPLETE ONLY A OR B
Page 1/4
CPSA - Complaint Form
(child, mother, guardian etc.)
Please provide the following details on the physician(s) you are complaining about. Please note we
will send a copy of this complaint form and attachments to the physician(s). We may also ask the
medical oce/hospital to provide personal identiable information such as diagnostic, treatment
and patient care information. A separate release may be required.
Identify any other individual(s) who provided medical care or may have information about the
incident(s) (e.g., family physician, other physician, nurse, oce sta or family members). We may
contact them for a response and send them a copy of your complaint.
3. Physician and location details:
4. Others with rsthand information:
First/Last Name Specialty
Name of medical oce/hospital
Address Phone #
Date and location of Incident(s)
Page 2/4
CPSA - Complaint Form
First/Last Name Specialty
Name of medical oce/hospital
Address Phone #
Date and location of Incident(s)
First/Last Name Specialty
Name of medical oce/hospital
Address Phone #
Date and location of Incident(s)
First/Last Name Specialty
Name of medical oce/hospital
Address Phone #
Date and location of Incident(s)
First/Last Name Specialty
Name of medical oce/hospital
Address Phone #
Date and location of Incident(s)
First/Last Name Specialty
Name of medical oce/hospital
Address Phone #
Date and location of Incident(s)
Page 2/4
What do you hope will happen as a result of your complaint?
Have you attempted to resolve your complaint directly with the physician(s) involved?
Yes No
5. Complaint details:
Page 3/4
CPSA - Complaint Form
Have you submitted a complaint to another organization? (e.g., law enforcement, AHS,
Covenant Health, a facility or clinic manager, Alberta Ombudsman, OIPC, AHCIP etc.)
Yes No If yes, please specify:
Describe in detail what the physician(s) did or did not do causing you to complain, including
where and when it happened. Please attach copies of any documents that support your
complaint. Please note we will send a copy of this form to the physician(s) you identify.
Privacy is important to us!
We collect, use and/or disclose your personal information with your consent unless otherwise authorized or
required by legislation. As per our CPSA Privacy Statement, we collect and use your personal information to
do our CPSA work, which is to protect the public and to guide and regulate Alberta physicians.
description continued...
Attach additional pages if necessary
Page 4/4
CPSA - Complaint Form
Send completed complaint form and signed & dated consent form to:
Professional Conduct Department
College of Physicians & Surgeons of Alberta
2700-10020 100 ST NW, Edmonton, AB T5J 0N3
Signature of person making complaint Date signed (day/month/year)
Patient to sign and date below when applicable:
As the patient, my signature below is consent for the College of Physicians & Surgeons
of Alberta to share information about my complaint to the person completing this form. I
understand this information may include personal identiable information, such as diagnostic,
treatment and patient care information.
Patient’s signature Date signed (day/month/year)
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Filing a Complaint 1. Complete this form with (College of Physicians & Surgeons of Alberta)

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Completed 4 May 2021

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