Medical Staff Appointment Application

Medical Affairs - Application - Appointment to the Medical Staff of Sault Area Hospital

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Sault Area Hospital Application for Privileges

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.

CPSO Proof of Registration ~ RCPSC Certificate if you are a Specialist ~ Membership with Canadian Medical Protective Association (CMPA) ~ Copy of Current CV ~ Immunization Records ~ Proof of N95 if applicable ~ Void cheque if applicable ~ Electronic Photo for a photo ID badge

Please note that this electronic form does not have a save feature. Be prepared to complete it in one session, allowing enough time to finish the entire application and upload all required documents before submitting.

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
Medical Directives (Exception: Radiologists and Pathologists)
Occupational Health Compliance
Procedures List
Consent Application for Appointment

Today's Date (mm/dd/yyyy)(Required)

MM slash DD slash YYYY

Format: mm/dd/yyyy

Department of:(Required)

As a member of the following category of medical staff:(Required)

Please check your medical staff category:(Required)

General Practice

Specialist

Please complete the following information:

Full Name(Required)

First Middle Last

Date of Birth (mm/dd/yyyy)(Required)

MM slash DD slash YYYY

Format: mm/dd/yyyy

Place of Birth(Required)

Social Insurance Number

Gender(Required)

Languages spoken in addition to English

Residence (Home) Address(Required)

Street Address Address Line 2 City Province Postal Code

Cell Phone(Required)

Email(Required)

Consent Email to Finance Team(Required)

I give permission to share my email address with the Finance Department of the SAH to facilitate electronic remittance of payment for services rendered, where applicable.

Office Information

Office Address

Street Address Address Line 2 City Province Postal Code

Office Phone

Office Fax

Do you have your OHIP billing number?(Required)

Yes

Pending

If pending, please forward your OHIP Billing Number to Medical Affairs upon receipt.

OHIP Billing Number(Required)

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OHIP Billing Number Pending

Yes

Please, check if OHIP Billing Number is pending.

Emergency Contact Information

This information is helpful if the hospital needs to contact someone on your behalf:

Name(Required)

Surname (last name) Given name(s)

Relationship to Applicant(Required)

Home Address(Required)

Street Address Address Line 2 City Province Postal Code

Phone (Daytime)(Required)

Phone (Other)

License Information

Are you licensed to practice in Ontario(Required)

Yes

College of Physicians & Surgeons of Ontario (CPSO) License number:(Required)

Royal College Physicians and Surgeons of Canada (RSCPC) Fellowship ID License number:(Required)

Present Insurance Provider (CMPA) and Number(Required)

Please, submit a copy of your College of Physicians & Surgeons of Ontario (CPSO) certificate

Max. file size: 100 MB.

Please, submit a copy of your Royal College Physicians and Surgeons of Canada (RSCPC) Fellowship certificate

Max. file size: 100 MB.

Please, submit a copy of your CMPA Statement of Protection

Max. file size: 100 MB.

Liability Insurance Coverage(Required)

I hereby agree to carry Liability Insurance coverage, acceptable to the hospital, for as long as my appointment is in force.

Check and sign.

Signature(Required)

Educational Qualifications

In making this application, I provide the following record of my education.

Medicine

Degree(Required)

University(Required)

Start-End Year (yyyy-yyyy)(Required)

Post Graduate Training/Qualifications

Diplomas, Certificates, Degrees, Fellowships, etc.

Certification

University

Specialty

Start-End Year (yyyy-yyyy)

Certification

University

Specialty

Start-End Year (yyyy-yyyy)

Certification

University

Specialty

Start-End Year (yyyy-yyyy)

Graduate Training/

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

Training

Location

Start-End Year (yyyy-yyyy)

Training

Location

Start-End Year (yyyy-yyyy)

Training

Location

Start-End Year (yyyy-yyyy)

Eligibility to Sit Certificate Examinations

Complete only if you are waiting to write your examinations:

Royal College of Physicians and Surgeons of Canada

Yes

Specialty

Date (mm/dd/yyyy) exams to be taken:

MM slash DD slash YYYY

Format: mm/dd/yyyy

College of Family Physicians of Canada

Yes

Date (mm/dd/yyyy) exams to be taken:

MM slash DD slash YYYY

Format: mm/dd/yyyy

Medical Staff Appointments

Please include all appointments in reverse chronological order.

Teaching Appointments/

Appointment

Location

Start-End Year (yyyy-yyyy)

Appointment

Location

Start-End Year (yyyy-yyyy)

Hospital Staff Privileges/

Past and Present

Hospital

Status

Active, Associate, etc.

Start-End Year (yyyy-yyyy)

Hospital

Status

Active, Associate, etc.

Start-End Year (yyyy-yyyy)

Hospital

Status

Active, Associate, etc.

Start-End Year (yyyy-yyyy)

Professional Conduct

The following questions are to be answered “Yes” or “No”. For every “Yes” answer, please attach a comprehensive explanation.

I. Have you ever applied anywhere for a medical license, certificate of registration or permit to practise and had such application rejected?(Required)

Yes