Applications/Methadone Approval
Methadone Approval
Application Form
Physician Information:
Surname: _____________________________________ Given Names: _______________________________________
CPSA registration number: ________________________ Specialty: _________________________________________
Postgraduate Training: _______________________________________________________________________________
Primary Practice Address: _____________________________________________________________________________
City: ___________________________________ Province:____________________ Postal: ______________________
Phone Number (with area code): ___________________________ Fax Number: ________________________________
Email Address: ______________________________________________________________________________________
Mailing Address (if different from above): ________________________________________________________________
City: ___________________________________ Province:____________________ Postal: ______________________
Type of Practice: □ Solo □ Group
Methadone Approval for: □ Opioid Use Disorder (OUD) - General □ Opioid Use Disorder (OUD) – Patient Specific
□ Analgesia - General □ Analgesia – Patient Specific
If patient specific, name of patient(s): ___________________________________________________________________
Qualifications and Experience:
Describe qualifications and experience with methadone. E.g., courses, seminars, conferences, etc.
(See requirements & needed support documentation)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
□ I affirm that, to the best of my knowledge, the information on this form is true and accurate. I also understand
methadone approvals must be renewed every 3 years by re-applying to the College.
Signature: ______________________________________ Date: ________________________________________
(dd/mmm/yyyy)
Send completed application by mail or fax:
CPSA Methadone Program, 2700, 10020 100 Street NW, Edmonton AB T5J 0N3
Fax: 780-420-0651
Questions? Email: OATinfo@cpsa.ab.ca or call 1-800-561-3899
