Apply for Injury Management Consultant Approval - College of Physicians & Surgeons of Alberta

Personal identification

Name*

First Last

CPSA registration #*

Email*

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

Enter Email Confirm Email

Mailing address*

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

Business Phone #*

Business Fax #

Type of Practice*

Family
Specialty

Type of Specialty*

Declarations

I am active in the delivery of patient care in Alberta*

Yes
No

A significant part of my current clinical practice includes assessment and treatment of musculoskeletal disorders.*

Yes
No

I have a working knowledge of the biopsychosocial model of disability.*

Yes
No

I use established techniques and scales to assess and document the character and degree of pain experienced by patients.*

Yes
No

I regularly refer to practice guidelines and consensus statements developed by reputable medical sources.*

Yes
No

I intend to follow the Diagnostic & Treatment Protocols Regulations of the Insurance Act of Alberta to the best of my ability.*

Yes
No

I acknowledge that continuing as an Injury Management Consultant may in the future require participation in or successful completion of prescribed education.*

Yes
No

Signature

Consent*

CPSA collects this information pursuant to the Minor Injury Regulation of the Insurance Act. Information in this form may be reviewed by CPSA to verify that an applicant meets the requirements set out in Division 2 of that Regulation, and may be disclosed to the Superintendent appointed under the
Insurance Act (Alberta). CPSA will also notify the Superintendent if a physician who has been recognized as an Injury Management Consultant ceases to meet the requirements of this Regulation.

I understand and agree to the above conditions.

Checking this box will act as your signature:*

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

Date*

Comments

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

Personal identification

Declarations

Signature

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