Medical Staff Appointment Application

Application - Appointment to the Medical Staff of Sault Area Hospital

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TO BE UPDATED

Instructions

Please complete the following appointment 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.

Today's Date

MM slash DD slash YYYY

Department of:

As a member of the following category of medical staff:

Please complete the following information:

Full Name

First Middle Last

Date of Birth

MM slash DD slash YYYY

Place of Birth

Social Insurance Number

Languages spoken in addition to English

Residence (Home) Address

Street Address Address Line 2 City Province Postal Code

Cell Phone

Pager Number

Consent

I agree to provide my email to the SAH Finance Department

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

OHIP Billing Number

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

Home Address

Street Address Address Line 2 City Province Postal Code

Phone (Daytime)

Phone (Other)

License Information

Are you licensed to practice in Ontario

Yes

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

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

Present Insurance Provider (CMPA) and Number

Consent

Liability Insurance Coverage

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

Educational Qualifications

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

Medicine

Degree

University

Year (yyyy)

Post Graduate Training/Qualifications

Diplomas, Certificates, Degrees, Fellowships, etc.

Certification

University

Specialty

Year (yyyy)

Certification

University

Specialty

Year (yyyy)

Certification

University

Specialty

Year (yyyy)

Graduate Training/

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

Training

Location

Year (yyyy)

Training

Location

Year (yyyy)

Training

Location

Year (yyyy)

Training

Location

Year (yyyy)

Training

Location

Year (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 exams to be taken:

MM slash DD slash YYYY

College of Family Physicians of Canada

Yes

Date exams to be taken:

MM slash DD slash YYYY

Medical Staff Appointments

Please include all appointments in reverse chronological order.

Teaching Appointments/

Appointment

Location

Year (yyyy)

Appointment

Location

Year (yyyy)

Appointment

Location

Year (yyyy)

Appointment

Location

Year (yyyy)

Appointment

Location

Year (yyyy)

Professional Practice/

Date

MM slash DD slash YYYY

Location

Type

Date

MM slash DD slash YYYY

Location

Type

Date

MM slash DD slash YYYY

Location

Type

Date

MM slash DD slash YYYY

Location

Type

Date

MM slash DD slash YYYY

Location

Type

Hospital Staff Memberships/

Past and Present

Hospital

Status

Active, Associate, etc.

Year (yyyy)

Hospital

Status

Active, Associate, etc.

Year (yyyy)

Hospital

Status

Active, Associate, etc.

Year (yyyy)

Hospital

Status

Active, Associate, etc.

Year (yyyy)

Hospital

Status

Active, Associate, etc.

Year (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?

Yes