Custody of Patient Records

As per our CPSA Standards of Practice, physicians who close or leave a medical practice are responsible for providing the College with information on the location of their patient records to ensure continued access and continuity of care.

Please fill out the form below to provide the required information.

Physician information

Name(Required)

Given name(s) Last name

CPSA registration number(Required)

Patient records information

My patient records are now in the custody of:(Required)

Medical Clinic

Physician

NOTE: This information is for public use.

Medical Clinic(Required)

Address(Required)

Street Address City Province Postal Code

Phone number(Required)

Email(Required)

Enter Email Confirm Email

Name(Required)

Given name(s) Last name

Address(Required)

Street Address City Province Postal Code

Phone number(Required)

Email(Required)

Enter Email Confirm Email

Effective date:(Required)

Dates should be typed in the format mm/dd/yyyy, as in 03/11/2023.

Signature

Checking this box will act as your signature:(Required)

I hereby certify to CPSA that the provided information are true and complete.

Date signed(Required)

Dates should be typed in the format mm/dd/yyyy, as in 03/11/2023.

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Admin fields

For CPSA use only

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QUEST Library(Required)

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Document Type(Required)

Hidden

Document Name(Required)

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Issuer(Required)

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Recipient(Required)

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