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

Physician information

Name:*

First Last

CPSA registration #:*

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 (DD/MM/YYYY)

(Click "+" icon to add an additional patient)

Additional comments?

Signature

Checking this box will act as your signature:*

I confirm the information on this form is accurate. I also understand OAT approvals must be renewed every five (5) years by re-applying to CPSA.

Date:*

Renewal requirements: Once granted, an OAT Initiation approval is valid for five years. Upon this time, physicians are notified to renew by return email under a streamlined process. OAT Maintenance approvals do not require renewal.

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

Comments

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

Physician information

Signature

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