Custody of Patient Records - College of Physicians & Surgeons of Alberta

Name(Required)

Given name(s) Last name

CPSA registration number(Required)

I am a physician or specialist who has maintained custodianship of my patient records throughout my practice.(Required)

Yes

If "No," please explain where your patient records have resided throughout your practice.(Required)

My patient records are now in the custody of:(Required)

Medical Clinic

Physician

NOTE: This information is for public use.

Medical Clinic(Required)

Address(Required)

Street Address City Province Postal Code

Phone number(Required)

Email(Required)

Enter Email Confirm Email

Name(Required)

Given name(s) Last name

Address(Required)

Street Address City Province Postal Code

Phone number(Required)

Email(Required)

Enter Email Confirm Email

Effective date:(Required)

Dates should be typed in the format mm/dd/yyyy, as in 03/11/2023.

Checking this box will act as your signature:(Required)

I hereby certify to CPSA that the provided information are true and complete.

Date signed(Required)

Dates should be typed in the format mm/dd/yyyy, as in 03/11/2023.