Certificate of Professional Conduct Request Form - College of Physicians & Surgeons of Alberta

Name

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Personal information

Full name*

First Last

CPSA Registration #*

Email*

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

Enter Email Confirm Email

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

Are you currently an undergraduate medical student, a postgraduate resident in Alberta, or have you completed postgraduate training in Alberta in the last 2 months? **

Yes
No

Your CPC request

Please fill out the information below

I'm requesting CPCs for the following:*

Click the + button to add more than one organization/individual.

Organization/Individual's Name	Email	Confirm email

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How many CPCs are you requesting in total*

This quantity must match the number of entries/rows listed above.

Please enter a number greater than or equal to 1.

Consent & signature

Understandings and Consent*

I understand that by submitting this form I give consent to CPSA to disclose the following information to the organization(s) identified above:

• Personal identifiers (physician’s name, date of birth, address)
• Qualifications and credentials
• Registration information (current register, registration history, terms, conditions and restrictions on licensure)
• Complaints (open, under appeal, complaints which led to a disposition other than taking no action but short of disciplinary action, former complaints that did not lead to formal action but which, in the opinion of the Registrar, may reflect conduct or a pattern of conduct that should be reported in the best interest of the public)
• Investigations (current and resolved)
• Disciplinary actions, excepting dismissals after a hearing (dates, particulars, findings, remedies or sanctions)
• Relevant non-disciplinary information (conditions arising from health or fitness to practice issues, peer review or other non-disciplinary issue or process, consent agreements or undertakings, consent withdrawal from practice or register, restriction or cancellation of hospital privileges)
• Findings of guilt, criminal and other (if known to CPSA)
• Professional litigation history (if known to CPSA)
• Other information considered relevant by the Registrar

I understand why I have been asked to disclose this information, and am aware of the risks or benefits of consenting or refusing to disclose this information. I also understand that I may revoke this consent at any time by submitting a written revocation to CPSA.

I understand that processing this request may take up to 15 working days.

I have read, understand and agree to the understandings and consent outlined above.

Checking this box will act as your signature:*

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

After clicking "Submit", you will be redirected to CPSA's Secure Payment Processing Portal to complete your payment. This can take a few seconds, and you should not refresh the page. We require payment to begin processing your request.

After completing payment, we will email you a receipt. That receipt is confirmation that your information was received and your request will be processed.

This request may take up to 15 working days to process.

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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*

Personal information

Your CPC request

Consent & signature

Admin fields

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