Non-Hospital Surgical Facility
Application for Privileges
f 2 Applications/Privileges – Non-Hospital Surgical Facility
FACILITY INFORMATION (Please Print)
Facility Name: ____________________________________ Medical Director: ____________________________
APPLICANT INFORMATION (Please Print)
CPSA Registration Number: ____________________________
Last Name: ___________________________________________ Given/First Names: __________________________
Street Address: __________________________________________________________________________________
City: _______________________________________________ Postal Code: ________________________________
Telephone Number: (______) ____________________________ Fax Number: (______) _______________________
E-mail Address: _________________________________
Degree & Specialty: ______________________________________________________________________________
Current AHS Privileges: Yes No Specify: __________________________________________
ADDITIONAL DOCUMENTS REQUIRED WITH THIS APPLICATION
• If applicant has current privileges with Alberta Health Services (AHS), attach a copy of a recent Reference Letter
from the applicable AHS Zone Medical Affairs Office confirming those privileges. Examples of acceptable letters
include: Appointment Confirmation Letter and a Medical Staff Appointment Memorandum.
• If ap
plicant does NOT have current privileges with Alberta Health Services (AHS), attach a description of Training
and Qualifications and Experience with the procedure(s) AND letters from two physicians attesting to the skill
and judgment of the applicant to perform such procedures.
Anesthesia only – If the applicant does hold anesthesia privileges at another NHSF, a full application is not
required. Please complete the anesthesia checklist only.
• A c
ompleted Procedure Checklist. Select the linked sub-specialty from the list below:
Anesthesia Assisted Reproductive Technology (ART) Dermatology Extended-Stay
General Surgery Gynecology Ophthalmology Orthopedic Surgery
Stem Cell Regenerative Therapy - BMAC
Otolaryngology Plastic Surgery
Stem Cell Regenerative Therapy -
Only procedures included on the College’s list of Approved Procedures for Non-Hospital Surgical Facilities will be
considered with this application.