Opioid Agonist Treatment (OAT) Approval Form - College of Physicians & Surgeons of Alberta

Physician information

Name:*

First Last

CPSA registration #:*

TPP submission ID #:*

If you are not yet registered with TPP Alberta, please register here.

Specialty:*

Postgraduate training:*

Primary practice address:*

Street Address City Province Postal Code

Phone:*

Fax:

Email*

Enter Email Confirm Email

Mailing address same as above?*

Yes
No

Mailing address:*

If different from above

Street Address Address Line 2 City Province Postal Code

Type of practice:*

Solo
Group

OAT approval for:*

OAT Initiation
OAT Maintenance

If you are seeking OAT Maintenance approval, provide the name(s) of the patient(s)*

First Name	Last Name	Date of Birth (MM/DD/YYYY)

(Click "+" icon to add an additional patient). NOTE: Dates should be typed in the format mm/dd/yyyy, as in 03/15/2023.

Additional comments?

Signature

Checking this box will act as your signature:*

I confirm the information on this form is accurate. I understand CPSA requires a copy of my Proof of Training and a Letter of Support (if in Residency) to be sent to OATinfo@cpsa.ca immediately after submitting this application.

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

Questions? Email OATinfo@cpsa.ca or call 1-800-561-3899.

Name

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

Physician information

Signature

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