Fillable Non-Hospital Surgical Facility Application for Privileges (College of Physicians & Surgeons of Alberta)

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Non-Hospital Surgical Facility Application for Privileges (College of Physicians & Surgeons of Alberta)

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Non-Hospital Surgical Facility
Application for Privileges
1 o
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 -
ADSC
Urology
Only procedures included on the College’s list of Approved Procedures for Non-Hospital Surgical Facilities will be
considered with this application.
Non-Hospital Surgical Facility
Application for Privileges
2
of 2 Applications/Privileges – Non-Hospital Surgical Facility
MEDICAL DIRECTOR CHECKLIST
Please include the following with this application form and submit as ONE complete package to the College. Ensure
you retain a copy for your files:
AHS Reference Letter confirming applicant’s current privileges OR Description of Training and Qualifications and
Experience with procedure(s) along with two professional reference letters
If applicable, a copy of current ACLS certification
Completed sub-specialty Procedure Checklist
A
n incomplete application will delay processing. If you have any questions completing this form, please contact our
Accreditation Department at 780-969-5002 or 1-800-320-8624 ext. 5002 (in Alberta).
P
rivacy Notice: The College of Physicians & Surgeons of Alberta collects, uses and/or discloses your personal
information with your consent or as authorized or required by law and in accordance with our Privacy Statement.
We collect and use your personal information in order to support the business of the College, specifically protect the
public and to guide and regulate our members.
A
pplicant Signature: ________________________________ Date: _____________________________
Me
dical Director Signature: ___________________________ Date: _____________________________
P
lease return your completed application and required documents (together as one package) to the
College of Physicians & Surgeons of Alberta by fax: 780-428-2712 or by mail:
2700 - 10020 100 ST NW, Edmonton AB T5J 0N3
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Non-Hospital Surgical Facility Application for Privileges (College of Physicians & Surgeons of Alberta)

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Completed 4 May 2021

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