Provision of Professional Services
Most Responsible Physiotherapist Provision of Professional Services Agreement with the College
Practice Setting Information
Name of Practice Setting
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Practice Setting Address
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Street Address
Street Address Line 2
City
Province
Postal Code
Designated Owner's Name
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First Name
Last Name
Designated Owner's Email
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example@example.com
Most Responsible Physiotherapist
Most Responsible Physiotherapist's Name
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First Name
Last Name
Most Responsible Physiotherapist's Registration Number
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Registration number assigned by the College of Physiotherapists of Alberta
Most Responsible Physiotherapist's Email Address
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Appointment
As a regulated member of the College of Physiotherapists of Alberta, on the General Register, I accept:
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The appointment of ‘Most Responsible Physiotherapist’ for the practice setting named in this agreement.
As the Most Responsible Physiotherapist, I understand:
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It is my responsibility to work with the Designated Owner to ensure that the conditions within the practice setting positively enable physiotherapists in the practice setting to fulfill their professional requirements.
Agreement
As the Most Responsible Physiotherapist, I agree to:
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Provide oversight at the practice setting to ensure that the College of Physiotherapists of Alberta's Standards of Practice, Code of Ethical Conduct, and other professional obligations are met.
As the Most Responsible Physiotherapist, I agree to:
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Provide oversight at the practice setting to ensure that all health information created, collected, used, or disclosed in the provision of physiotherapy services complies with the Health Information Act.
As the Most Responsible Physiotherapist, I agree to:
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Ensure that existing business plans, policies, and procedures are consistent with the professional responsibilities of physiotherapists.
As the Most Responsible Physiotherapist, I agree to:
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Ensure that new or revisions to business plans, policies, and procedures are consistent with the professional responsibilities of physiotherapists.
As the Most Responsible Physiotherapist, I agree to:
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Work with the Designated Owner if a situation arises where an operational practice or business decision limits a physiotherapist's ability to adhere to their professional responsibilities and performance expectations, to address the situation, making sure that workplace conditions enable professional practice.
As the Most Responsible Physiotherapist, I agree to:
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Inform the College of Physiotherapists of Alberta immediately if I cease to provide services at this practice setting or resign from the role of Most Responsible Physiotherapist.
As the Most Responsible Physiotherapist, I agree to:
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Inform the College of Physiotherapists of Alberta immediately if I am officially employed at the practice setting but on leave and not actively providing services at the practice setting.
As the Most Responsible Physiotherapist, I agree to:
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Inform the College of Physiotherapists of Alberta immediately if I continue to provide physiotherapy services at the practice setting but am no longer willing or able to continue to fulfil the responsibilities of Most Responsible Physiotherapist.
As the Most Responsible Physiotherapist, I agree to:
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Inform the College of Physiotherapists of Alberta immediately if I leave the role of Most Responsible Physiotherapist because, in my opinion, conditions within the practice setting do not enable physiotherapists to fulfill their professional responsibilities and apprise the College of the particulars of the situation.
Health Information Act (HIA) Attestations
As the Most Responsible Physiotherapist, I attest that:
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I understand that all health information created, collected, used, or disclosed in the provision of physiotherapy services is subject to the Health Information Act (HIA).
As the Most Responsible Physiotherapist, I attest that:
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I understand that physiotherapists are designated as "custodians" under the HIA and are responsible for complying with the requirements of the HIA, including the collection, use, disclosure, protection, and retention of health information created in the course of providing physiotherapy services.
As the Most Responsible Physiotherapist, I attest that:
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I understand that the HIA obligations apply regardless of practice setting or employment relationship.
As the Most Responsible Physiotherapist, I attest that:
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I understand that custodians are required to develop, implement, and maintain HIA-compliant policies and procedures for the management of health information.
As the Most Responsible Physiotherapist, I attest that:
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I understand the difference between a "custodian" and an "affiliate" under the HIA and when and with whom a physiotherapist may enter into an "affiliate relationship" with another HIA-designated "custodian".
As the Most Responsible Physiotherapist, I attest that:
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I understand that if a physiotherapist enters into an "affiliate relationship" with another HIA-designated "custodian", that the relationship must be clearly established in writing, and roles and responsibilities for managing health information must be clearly defined.
As the Most Responsible Physiotherapist, I attest that:
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I understand that physiotherapists who leave this practice setting must ensure there are appropriate arrangements in place for the ongoing lawful custody and control of physiotherapy records. If they have not previously entered into an "affiliate relationship" with another HIA designated custodian, they retain this responsibility unless they designate an eligible authorized custodian to assume custody of the records.
Submission
Submission Date
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Year
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Month
Day
Date Picker Icon
Most Responsible Physiotherapist's Signature
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