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Reappointment Application – Supportive

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Medical Staff Reappointment
Reappointment Application – Supportive

Reappointment Application - Supportive (July 1, 2025 to June 30, 2026)

Instructions

Please complete the following reappointment application.

Make sure you have proof of your documentation, membership with the Canadian Medical Protective Association (CMPA) or evidence of professional liability insurance coverage to submit with your application as you will be asked to upload. (Group Health Centre provides a copy of their physician’s insurance coverage therefore GHC physicians do not need to attach)

You will not be able to save this application and return to add your documentation.

I, hereby apply for reappointment to the medical staff of the Sault Area Hopsital, within the Supportive medical staff category:(Required)

(enter your name)

With privileges in the department of:(Required)

Please indicate any CHANGES to the following information:

Home Address

Home Phone

Office Address

Office Phone

Email

Mobile Phone

Pager Number

Fax Number

In applying for reappointment I am requesting privileges as approved and attached to my previous application with the following changes (additions or deletions):

Education

In making this application, I provide the following record of my continuing education and contribution to the hospitals' operation:

1. Continuing Medical Education:

Did you satisfy the requirements of the CPSO for Continuing Medical Education participation as outlined by either the CFPC or the RCPSC at the time of your last renewal of licensure in Ontario?

Yes

No

2. Service to Other Hospitals and Health Organizations During the Past Year:

(Other Health Organizations include the O.M.A., local allied health groups,etc.)

Please identify positions held, committee representation and organization:

Professional Conduct

3. Have you been the defendant in any malpractice litigation or any litigation related to the practice of medicine during the past five (5) years in which a finding of negligence was made against you or in which negligence was admitted by you or on your behalf?(Required)

Yes

No

As the answer is YES to question 4, please provide details related to when, where, the circumstances regarding your involvement, and the disposition of the action.(Required)

4. Since July 1st of last year, have you ever been found guilty of professional misconduct?(Required)

Yes

No

5. Since July 1st of last year, have you ever agreed to a settlement to avoid anyproceeding or disciplinary action in respect of your professional conduct?(Required)

Yes

No

6. Since July 1st of last year, have you been the subject of an investigation by any licensing body in Ontario, or anywhere else?(Required)

Yes

No

As the answer is YES to question 6, please attach documentation indicating the reason for and the current status of the investigation.

Drop files here or

Max. file size: 100 MB.

7. Since July 1st of last year, has your name been placed on a list restrictingyour purchasing or prescribing of narcotic or restricted drugs?(Required)

Yes

No

8. Are you currently suffering from a condition that impairs your ability to practice medicine? A condition that impairs your ability to practice medicine means a condition that adversely affects your judgment or your ability to practice medicine in a safe, competent, ethical and professional manner. Conditions that are being treated such that they do not impair your ability to practice medicine do not need to be disclosed. You should consult with your treater(s) if you are uncertain if your condition is being sufficiently treated and does not require disclosure.(Required)

Yes

No

Note: SAULT AREA HOSPITAL recognizes that physicians, like their patients, experience physical and mental health conditions. Physicians should seek treatment, as needed, to ensure they are not practicing medicine while impaired. Resources available to physicians suffering from a medical condition include the OMA’s Physician Health Program, which provides confidential support (https://php.oma.org), as well as a variety of supports set out on the Physician Wellness page of the CPSO’s website (https://www.cpso.on.ca/en/Physicians/Your-Practice/Physician-Advisory-Services/Physician-Wellness). Additionally, applicants are advised that disclosure of any medical conditions in this credentialing application will be kept in strict confidence and will only be used to evaluate what privileges will be granted to a physician for the upcoming credentialing year.

9. Since July 1st of last year, have you been convicted of a criminal offence inCanada or else where for which you have not received a pardon?(Required)

Yes

No

As the answer is YES to question 9, please provide information regarding the reason for and the current status of the conviction.(Required)

10. Since July 1st of last year, have you been charged with any criminal offences in Canada or elsewhere that currently remain outstanding?(Required)

Yes

No

As the answer is YES to question 10, please provide information regarding the reason for and the current status of the charges.(Required)

Emergency Contact Information

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

Name

Surname (last name) Given name(s)

Relationship to Applicant

Phone (daytime)

Phone (other)

Email

Home Address

Street Address Address Line 2 City Province Postal Code

Requirements

Please check your medical staff category to determine additional submission requirements:(Required)

Physicians

RN (EC)

NOTE: Please attach a copy of your current professional liability insurance coverage satisfactory to the Board. (Group Health Centre provides a copy of their physician’s insurance coverage therefore GHC physicians do not need to attach.)

Physicians(Required)

I confirm that my license with the College of Physicians and Surgeons of Ontario is active and in good standing.

I will promptly notify the SAH COS office if the status of my license changes any time prior to next reappointment cycle.

RN (EC)(Required)

I confirm that my license with the College of Nurses of Ontario is active and in good standing.

I will promptly notify the SAH COS office if the status of my license changes any time prior to next reappointment cycle.

Physicians:

Drop files here or

Max. file size: 100 MB.

Membership in the Canadian Medical Protective Association (CMPA), or evidence of individual insurance.

RN(EC):

Drop files here or

Max. file size: 100 MB.

Please attach evidence of professional liability insurance coverage satisfactory to the Board.

Consent

Consent - Reappointment(Required)

Check here to agree to the following: In accepting the privileges and facilities afforded me for the care of my patients, I hereby declare that, if reappointed to the medical staff, and in consideration of such appointment, agree and undertake to conform to, and to govern myself in accordance with the hospitals’ bylaws, the hospitals’ Code of Behaviour, the Code of Ethics of your Profession (Physician, Dentists, Midwives), Continuing medical education requirements, and practice in accordance with the Public Hospitals Act of Ontario.

Date

MM slash DD slash YYYY

Name(Required)

First Last

Preferred Email(Required)

A copy of your application will be sent to your preferred email address to verify successful submission.

Phone

This field is for validation purposes and should be left unchanged.

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We acknowledge that Sault Area Hospital is situated upon the traditional territory of the Anishnaabeg, specifically Garden River First Nation and Batchewana First Nation, as well as the Métis People. This land, Baawaating, is the historic meeting place for Indigenous people across North America. This territory is included in the Robinson Huron Treaty of 1850. We say miigwetch to all Indigenous and Métis partners for sharing this land, and we recognize their enduring presence.

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