Provision of Professional Services
Change of Most Responsible Physiotherapist (Regulated Owner Practice Setting)
Practice Setting Information
Name of Practice Setting
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Practice Setting Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Ownership
Designated Owner's Name
*
First Name
Last Name
Designated Owner's Phone Number
*
Format: (000) 000-0000.
Designated Owner's Email Address
*
Most Responsible Physiotherapist
PAST OR DEPARTING Most Responsible Physiotherapist's Name
*
First Name
Last Name
NEW Most Responsible Physiotherapist's Name
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First Name
Last Name
NEW Most Responsible Physiotherapist's Registration Number
*
Registration number assigned by the College of Physiotherapists of Alberta
NEW Most Responsible Physiotherapist's Email Address
*
A copy of this application, once submitted, will be emailed to the Most Responsible Physiotherapist at the email address above so they are aware of the application status.
File Upload: Agreement
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NEW Most Responsible Physiotherapist's signed CPTA Provision of Professional Services Agreement. Only PDF documents are accepted.
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File Upload: Certificate of Completion
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NEW Most Responsible Physiotherapist Module certificate of completion dated within the last two years. Only PDF documents are accepted.
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Acknowledgements
As the designated owner, I agree to:
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Positively enable the Most Responsible Physiotherapist and any other physiotherapists working at the practice setting named in this application to meet their professional responsibilities established in the College of Physiotherapists of Alberta's Standards of Practice, Code of Ethical Conduct and governing legislation.
As the designated owner, I agree to:
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Positively enable the Most Responsible Physiotherapist and any other physiotherapists working at the practice setting named in this application to meet their professional responsibilities established in the Health Information Act.
As the designated owner, I agree to:
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Positively enable the Most Responsible Physiotherapist to fulfil their obligations in the Provision of Service Agreement.
As the designated owner, I agree to:
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Immediately inform the College of Physiotherapists of Alberta if the Most Responsible Physiotherapist named in this application ceases to be the most responsible physiotherapist at this practice setting.
As the designated owner, I agree to:
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Within 30 days of the Most Responsible Physiotherapist's resignation, submit a Change of Most Responsible Physiotherapist Application to the College of Physiotherapists of Alberta.
As the designated owner, I agree to:
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Advise the College of Physiotherapists of Alberta of any and all changes to the information collected on this application either before or after approval.
As the designated owner, I certify and declare that:
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The information provided on this application is true.
Submission
Submission Date
*
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Year
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Month
Day
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Designated Owner's Signature
*
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