Review a Dismissed Complaint Request Form - College of Physicians & Surgeons of Alberta

A request to review a dismissed complaint must be submitted to CPSA within 30 days:

If your dismissal letter is sent by email, the 30-day period begins on the date CPSA sends the letter to the email address you provided when you filed your complaint.
If your dismissal letter is sent by registered mail, the 30-day period begins 7 days after the letter is given to a carrier for delivery (to allow for reasonable carrier processing time).

Please complete the form with as much detail as possible, outlining specific reasons for why you believe the decision to dismiss your complaint was unreasonable.

A non-refundable administrative fee of $200+GST is required to process a request for review. You will be emailed instructions on how to make your payment after your form is submitted and reviewed.

If you are requesting more than one review, a separate form and payment must be submitted for each dismissed complaint.

Comments
This field is for validation purposes and should be left unchanged.
Name and Address:*
First Name Last Name
Address:*
Address Line 1 Address Line 2 City Province Postal Code
Phone:*
Email:*
Enter Email Confirm Email
How would you like to receive correspondence related to this request? This includes all notices you are entitled to under part 4 of the Health Professions Act.*
- Mail
- Email
Complaint file number (this can be found on your dismissal letter):*
Please describe in detail the reasons why you feel the Complaints Director’s decision to dismiss your complaint was unreasonable.*
Please note that simply restating the issue or saying you disagree with the decision does not mean the decision was unreasonable. An example of an unreasonable decision is one that doesn’t make sense based on the facts of the complaint, the evidence provided or applicable standards of medical practice:
Additional documents (if any):
You do not need to submit any supplemental documents with your request for review or the original documents that you submitted to the Complaints Director. However, you may submit up to 10 pages of additional documents highlighting any evidence gaps, to support the reasons why you believe the decision to dismiss is unreasonable. Please note, all pages must be submitted as one file.
Max. file size: 128 MB.
I am the complainant and am formally requesting a review of the dismissed complaint noted above, under the Health Professions Act section 68(1).*
By checking this box, I confirm that the details contained in my request for review are correct. I further understand that CPSA will be managing information about me which may include personal, identifiable information.

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