Dentistry Staff Appointment Application

In addition to completion of the electronic application you will be asked to provide the following either by uploading where indicated in the application and/or by email to the SAH Medical Affairs contact.

Proof of registration with the Royal College of Dental Surgeons of Ontario ~ Copy of Current CV ~ Proof of Liability Insurance Coverage ~ Electronic Photo for a photo ID badge

Instructions

Please complete the following application for appointment of privileges at Sault Area Hospital which includes:

• Application
• Authorization for Release of Information
• Electronic Signature Authorization Form
• Privacy and Confidentiality Agreement
• Immunization Consent for Exposure
• Consent Application for Appointment

Post Graduate Training/Qualifications

Diplomas, Certificates, Degrees, Fellowships, etc.

Graduate Training/

Internships, Residencies, Research Fellowships, etc. in reverse chronological order

Hospital Staff Privileges/

Past and Present

Authorization for the Release of Information

Sault Area Hospital/

(1) A listing of all privileges held while a member of the medical staff;

(2) The term and nature of my appointment;

(3) Identification of any offices or appointments held; and

(4) Identification of any circumstances related to any disciplinary measure imposed against me while a member of the medical staff, including the suspension of privileges for whatever reason.

In accordance with the Authentication Electronic Signature Policy in the Administration Manual on Authentication/ Electronic Signature which I have read, all reports which I dictate will be considered authenticated on the basis of my signature below, the utilization of my unique three digit dictation I.D. code, and the statement of my name at the beginning of each piece of dictation, unless otherwise indicated. The electronic signature will be considered replacement of my hand-written signature for electronically generated reports/orders by utilization of my sign-on and password. It is the responsibility of the dictating individual to read the transcribed report. If an edit is required, the corrections must be made in writing on the original and returned to the appropriate department, or an addendum must be dictated. Refer to policy Authentication Electronic Signature Policy.

Authentication Electronic Signature Policy

Click next to complete the Privacy and Confidentiality Agreement – Medical Staff

Privacy and Confidentiality Policy

Internet Access Policy

Click next to complete Occupational Health Compliance

Click next to complete final submission