College of Physicians and Surgeons of British Columbia300–669 Howe Street Vancouver BC V6C 0B4 www.cpsbc.ca

Telephone: 604-733-7758 Toll Free: 1-800-461-3008 (in BC) Fax: 604-733-3503

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NON-HOSPITAL MEDICAL AND SURGICAL FACILITIES ACCREDITATION PROGRAM

Application for Appointment to a Non-Hospital Medical/Surgical FacilitySCHEDULE G

FACILITY INFORMATION

Facility name:

NHID: Submission date:

APPLICATION IDENTIFICATION

Applicant name:

Address:

City: Province/state:

Postal code/zip code: Phone number:

Email address:

CPSID/DCID: Proposed start date:

Specialties:Surgical

ENT OrthopedicGeneral PediatricGynecology PlasticsNeurosurgery UrologyOphthalmology Vascular

MedicalAnesthesiaDermatologyRadiology

OtherDentalSurgical assistPodiatryOther

APPLICANT QUALIFICATIONS

Granting of privileges for physicians working at non-hospital medical and surgical facilities is governed by the College Bylaws under the Health Professions Act, RSBC 1996, c.183 and the NHMSFAP policies.

GENERAL EXPERIENCE

Please complete as applicable.Specialty Experience (years) All hospitals at which full active

privileges are held Specialty degree

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College of Physicians and Surgeons of British ColumbiaApplication for Appointment to a Non-Hospital Medical/Surgical Facility – Schedule G

REFERENCES

1. If privileges are currently or were previously held in an acute care hospital, or you recently completed a residency program, please provide:a. One letter of reference from each of the following:

• head of hospital department or division, chief of staff, or program directorSurname: First name:

• peer from your specialty, or immediate supervisorSurname: First name:

Each referee must complete the Reference for Applicants for Privileges at Non-Hospital Medical/Surgical Facility.

ANDb. A letter from the hospital confirming the privileges held in your specialty, stating that you are in good standing with

the hospital.

2. For procedures not generally performed in an acute care hospital:a. a description of training, qualifications and experience with the procedure(s)b. two references from peers in your specialty attesting to competency

References must have current knowledge of the individual and their practice.

SPECIAL TRAINING

Please submit documentation detailing special qualifications and/or skills you have attained through additional training if applicable.

Qualification/training Program level Date (YYYY-MM-DD) Attached

CPR (mandatory, except for anesthesiologists)

ACLS

PALS

Other

APPLICANT PROCEDURES

Please attach a list of procedures for which you seek approval to this form. Procedure list attached.With respect to the list of procedures for which you seek approval, you acknowledge awareness of the requirements of section 2-3(3) of the Bylaws which states: A registrant must practise medicine within the scope of his or her training and recent experience and must not engage in a medical practice that he or she is not competent to perform, and failure to comply with this requirement may result in a finding of unprofessional conduct.

APPLICANT PERSONAL INFORMATION

If the answer to any of the below questions is yes, please provide brief details in a separate letter to the medical director, unless previously submitted.

1. Have you ever had an application for professional licensure rejected or professional licensure revoked, suspended or restricted?

Yes No

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College of Physicians and Surgeons of British ColumbiaApplication for Appointment to a Non-Hospital Medical/Surgical Facility – Schedule G

2. Are you aware of any factors that may limit your suitability to work at this facility or which may adversely affect or impact upon your professional performance?

Yes No

3. Have you had any restrictions placed on your surgical privileges or practice by a hospital or a medical/surgical facility?

Yes No

APPLICATION FOR APPOINTMENT FEES$250 – physician, dentist or podiatrist$100 – surgical assist$500 – out-of-province physician$1,000 – urgent requests for review(This applies to all classes of applicants. Processing time is five working days or less depending on the urgency of the request and the NHMSFAP resources available to process the application.)

Under NHMSFAP policy, the College has 60 days to review and notify the medical director of any limits or conditions on a physician licence affecting the privileges being granted.

APPLICANT AUTHORIZATION

I hereby certify that the information provided in this application is true. I hereby authorize the College of Physicians and Surgeons of British Columbia to make such inquiries about me as it considers appropriate in connection with this application. I authorize the committee for the Non-Hospital Medical and Surgical Facilities Accreditation Program to revoke any privileges or approval to practise at the above named facility if it subsequently appears that I have, by any omission or commission, given false, misleading or ambiguous information in respect of any question on this application form.

Applicant signature: Date:

FACILITY DIRECTOR APPROVAL

I certify that I am satisfied that this application for appointment to the medical staff of our facility meets all the requirements of the College Bylaws under the Health Professions Act, RSBC 1996, c.183 and the NHMSFAP policies. I also certify that the physician is qualified to perform the approved procedures within our facility.

Facility director signature: Date:

The information in this form is collected under the authority of part 5, section A of the Bylaws under the Health Professions Act, RSBC 1996, c.183. The information provided will be used to process your application for appointment to facility medical/surgical staff. If you have any questions about the collection and use of this information, please contact the College at 300–669 Howe Street, Vancouver, BC, V6C 0B4 or by phone at 604-733-7758 or 1-800-461-3008 (toll free in BC).

COLLEGE USE ONLY

NHID:

Date received:

Confirmation of licensure to the facility: