Change to Physician Sponsorship Form - College of Physicians & Surgeons of Alberta

Check all the apply.

Sponsor is withdrawing sponsorship of the above physician.

The physician outlined above is changing or adding a scope of practice. If a physician already practising medicine in Alberta wants to add a new medical service to their practice, or they have existing practice permit restrictions they should let us know first by applying for a change in scope assessment. We will review the application and let the physician know if they need an assessment and additional training before offering this new service to patients. (The physician is responsible for any associated costs for any assessment or additional training).

The physician outlined above is changing their primary practice location (different from the one they were originally sponsored for).
NOTE: If a physician plans to relocate their practice, they must notify us at least 45 days before they move by completing the Notification of Change Form in the CPSA Portal.

The physician outlined above is adding an additional practice location (different from primary location they were originally sponsored for).

The physician outlined above is adding a locum location (in addition to their primary practice location they were originally sponsored for).

NOTE: CPSA will only accept change to sponsorship forms signed by an approved sponsor.

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

Providing your CPSA registration # will help us resolve your inquiry more efficiently.

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

Change to Physician
Sponsorship Form

Signature

Admin Fields

Questions about sponsorship?

Innovation at CPSA