Change to an Accredited Facility Form - College of Physicians & Surgeons of Alberta

Type of facility:

Facility Name:*

Facility Number:

Tell us what's changed

We only need the new/updated information. If nothing has changed, or the field does not apply to your facility, please leave it blank.

Date change is effective (dates should be typed in the format mm/dd/yyyy, as in 03/15/2023).*

Facility Name:

Facility Contact Email:

This is the email address we will send a submission confirmation notification to.

Enter Email Confirm Email

Testing/Procedures/Anesthesia:

Hidden

Imaging Services:

Medical Director:

Manager / Supervisor:

Address:

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

Phone:

Email

Enter Email Confirm Email

Other (please specify):

Notes:

Checking this box will act as your signature:*

Name of Medical Director/Designate:*

Email:*

This is the email address we will send a submission confirmation notification to.

Enter Email Confirm Email

Date (dates should be typed in the format mm/dd/yyyy, as in 03/15/2023).*

Email

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