Certified Examiner/Injury Management Consultant Approval Form - College of Physicians & Surgeons of Alberta

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Personal identification

Name*

First Last

CPSA registration #*

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 in active clinical practice in Alberta.*

Yes
No

My practice includes a substantial component of assessment and treatment of musculoskeletal disorders.*

Yes
No

I have substantial experience conducting independent medical examinations (IMEs).*

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 have a working knowledge of the International Classification of Diseases.*

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 have a working knowledge of CPSA’s guideline on Medical Examinations by Non-Treating Physicians (NTME's).*

Yes
No

I acknowledge that my continuance as a Certified Examiner may in the future require participation in or successful completion of prescribed education.*

Yes
No

I have certification in the IME process such as that available from the American Board of Independent Medical Examiners (ABIME).*

Yes
No

Please describe formal training to conduct IMEs.*

How many IMEs have you done in the past three (3) years?*

Please enter a number greater than or equal to 0.

Signature

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 a Certified Examiner ceases to meet the requirements of this Regulation.

Checking this box will act as your signature:*

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

Email*

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

Personal identification

Declarations

Signature

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