Notification of Change Form

URL

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

Registrant information

Name*

First Last

CPSA Registration #*

Are you on the Provisional Register?*

The Provisional Register includes physicians and osteopaths who do not meet the criteria for the General Register yet, but are working on getting what they need to transfer to the General Register.

Yes
No

The changes listed below are effective as of (dates should be typed in the format mm/dd/yyyy, as in 03/15/2023.):*

Change reporting

What changes are you reporting?*

I am ending my registration with CPSA (Retirement, voluntary erasure, other)
I am changing practice details (Closing or opening practice, updating contact information)

What is the reason for ending your registration with CPSA?*

I am retiring
I am requesting voluntary erasure
Other

As a result of your retirement, what will be the status of your practice/clinic location?*

My current practice/clinic location will close, permanently, effective my retirement
My current practice/clinic location will be sold or transferred to new owners, effective my retirement
N/A - I am not the owner or manager of this location, and it will remain open

Retirement contact address*

Please note: Contact information will not be publicly released. CPSA will use it to send personal and confidential mail to.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If you have written a letter to notify us of your retirement, please attach it here.

This letter is not a requirement.

Accepted file types: pdf, word, png, jpg, jpeg, Max. file size: 5 MB.

Please describe the reason for ending your registration with CPSA.*

Because you are ending your registration, you must disclose the following:

Disclose where you will store patient records:*

Disclose how patients can access their records:*

Disclose a forwarding contact information including a mailing address*

Forwarding mailing address*

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What practice change(s) are your reporting?*

Select all that apply

Closing medical practice operations
Changes to professional contact information (address, phone, fax)
Changes to home contact information (address, phone, fax)
Changes to clinic/facility name only
Changes to physician's legal name

Are you opening a new medical practice at a new address?*

If "yes," please ensure you also select "Changes to professional contact information.”

Yes
No

Professional contact information (address, phone, fax)

Please complete all fields that require updates.

New clinic/facility name

New practice address

IMPORTANT NOTE: This address will be published on CPSA's Physician Directory.

Is the new practice address above privately or publicly owned?

Privately owned clinics are independently owned by individuals such as physicians or medical groups within the private sector.
Publicly owned clinics are owned and operated by a government (provincial or federal) or a public authority.

Privately owned
Publicly owned

Is the new pratice address above registered on CPSA’s Medical Clinic Registry?

Not sure if your clinic is registered? Use the search tool here.

Yes
No

Are you the designated medical director/medical lead at the practice address above?

Yes
No

New practice phone # (main phone line)

IMPORTANT NOTE: This phone # will be published on CPSA's Physician Directory.

New practice phone # (private phone line)

New practice fax #

IMPORTANT NOTE: This fax # will be published on CPSA's Physician Directory.

New practice email

Enter Email Confirm Email

If you have made a change to your professional address, how will you manage patients’ transfer of care?

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New clinic/facility name*

Physician’s legal name change

To process your name change, we need documented proof of your new name. Please attach documented proof when you submit this form.

Name*

IMPORTANT NOTE: This name will be published on CPSA's Physician Directory.

First Last

Please attach documented proof of your new name.*

Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.

Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 5 MB.

Home contact information (address, phone, fax)

Please complete all fields that require updates.

New home address

New home phone #

New cell phone #

New home fax #

New home email

Enter Email Confirm Email

Address designation

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Which address would you like published and publicly visible on CPSA's website?*

In accordance with the Health Professions Act, please identify which address you want publicly released and published on CPSA’s website.

Business address
Home address

To which address would you like your CPSA mail sent?*

In accordance to your Registration Agreement, CPSA needs one address to send personal and confidential CPSA mail to.

Business address
Home address

Additional information about your changes

Will these reported changes impact your participation in the Tracked Prescription Program (TPP Alberta)?*

Yes
No

Will these reported changes impact your professional corporation (PC)?*

Yes
No

Is there any additional information you would like us to know about changes to your practice? Please let us know.

Signature

Checking this box will act as your signature:*

I have reviewed the information in this form and confirm it is accurate.

Email*

This is the email address we will send your confirmation email to.

Enter Email Confirm Email

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Which address would you like published and publicly visible on CPSA's website?*

In accordance with the Health Professions Act, please identify which address you want publicly released and published on CPSA’s website.

Business address
Home address

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If you are closing or leaving a medical practice, you must:

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Please attach your AHS change to physician sponsorship form*

Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.

Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 5 MB.

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Admin fields

For CPSA use only

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Quest Library*

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Document Type*

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Document Name*

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Issuer*

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Recipient*

Before you begin

Are you on the Provisional Register and require ongoing sponsorship?

Are you a CPSA assessor, reviewer or sit on a CPSA Committee?

Registrant information

Change reporting

Because you are ending your registration, you must disclose the following:

Professional contact information (address, phone, fax)

Physician’s legal name change

Home contact information (address, phone, fax)

Address designation

Additional information about your changes

Signature

Admin fields

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