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

Type of facility:

Facility Name:*

If facility name has changed, please provide previous name here.

Facility Number:

Tell us what's changed

When filling out the fields below, 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).*

New Facility Name:

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Facility Contact Email:

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

Enter Email Confirm Email

Modality Change (+/-)

Tele – Radiology: Information Systems

Location of each off-site primary / secondary reporting stations used by imaging specialists for the supervision and interpretation/reporting of all tele-radiology exams (City, Town, Province).

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Imaging Services:

New Medical Director:

CPSA will contact the proposed New Medical Director for further information after receiving this notification.

New Manager / Supervisor:

New Address:

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

New Phone:

New Email

Enter Email Confirm Email

Other (please specify):

Additional Notes:

Signature

Checking this box will act as your signature:*

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

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).*

Name

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

Tell us what's changed

Signature

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