Ama Physician Locum Services Rural Locum Program Application Form Page 2
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1
2Please answer the following questions:
Have you ever applied for medical staff privileges and been denied?
Yes
No
If "Yes," please describe _______________________________________________________________________
____________________________________________________________________________________________
Have you ever been disciplined as a result of a malpractice suit?
Yes
No
If "Yes," please describe _______________________________________________________________________
____________________________________________________________________________________________
Have you ever had your medical staff privileges denied, revoked, suspended or limited (other than for
non-completion of medical records) by a hospital, regional health authority or provincial medical
regulatory body?
Yes
No
If "Yes," please describe _______________________________________________________________________
____________________________________________________________________________________________
The information included in this application is accurate and complete.
_____________________________________
_______________________________________________
Date
Signature of physician
**********************************************************************************
Release of Liability and Practitioner Statement for Credentialing and Privileging
I authorize and consent to representatives of the Alberta Medical Association, the College of Physicians
and Surgeons of Alberta, regional health authorities and faculties of medicine, providing in good faith
and without malice, information including otherwise privileged or confidential information for the proper
evaluation of my professional competence required for contracting with the Alberta Medical Association
to provide locum services in rural Alberta and NWT.
______________________________________
___________________________________________________
Date
Signature of physician
Please include with this application form:
Your CV (curriculum vitae) which includes:
•
A list of your continuing professional development activities within the past five years
A description of your recent clinical practice and a statement as to whether you restrict your
practice, and if so, how? Specifically, do you take emergency call for your specialty and look
after the entire range of patient problems and diseases within your specialty.
Photocopy of CPSA “Practice Permit” and Registration Understanding & Acknowledgement
•
Photocopy of CCFP Certification “if Held”
•
Photocopy of ATLS (current or past) and ACLS (current)
•
Photocopy of curent CMPA Membership Update
•
obtainable at RCMP or local city police
Original AHS Security Record Check
;
•
(a.k.a. Criminal Record Check )
detachment; cost to be reimbursed upon first assignment
Photocopy of Alberta Health Services (AHS) Medical Staff Appointment Letter
•
(more information: )
Send completed application to:
Barry Brayshaw
Director, AMA Physician Locum Services
12230 106 Ave NW, EDMONTON AB, T5N 3Z1
Fax: 780.732.3361 or E-Mail:
Revised – AUG 18, 2015
Page 2
Rural Locum Program Application Form
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