POS_Application: Practice Setting (Non-regulated Owner)

Provision of Professional Services

Application: Approval of Practice Setting (Non-regulated Owner Practice Setting)
Practice Setting Information
Name of Practice Setting
Practice Setting Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Practice Setting Phone Number
Format: (000) 000-0000.
Practice Setting Email
Social Media Profile
Website Address
Facebook
Twitter
LinkedIn
Instagram
TikTok
YouTube
Ownership

For the purpose of this application and any authorization granted, the "designated" owner is the contact person between the College of Physiotherapists of Alberta and the owner(s) of the practice setting. The designated owner needs to be knowledgeable of the regulatory responsibilities of registered physiotherapists and familiar with physiotherapy-related business operations.
Designated Owner's Name

First NameLast Name
Designated Owner's Phone Number
Format: (000) 000-0000.
Designated Owner's Email
File Upload: Designated Owner's Certificate of Completion

Provision of Professional Services Module. Designated Owner's certificate of completion dated within the last two years. Only PDF documents are accepted.
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Other Owner's Name

First NameLast Name
Other Owner's Name

First NameLast Name
Most Responsible Physiotherapist
Most Responsible Physiotherapist's Name

First NameLast Name
Most Responsible Physiotherapist's Registration Number
Registration number assigned by the College of Physiotherapists of Alberta
Most Responsible Physiotherapist's Email
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

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

Provision of Professional Services Module. Most Responsible Physiotherapist's certificate of completion dated within the last two years. Only PDF documents are accepted.
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Supporting Documents

All documents pertaining to the supporting document CATEGORY must be combined into one PDF file prior to uploading.
File Upload: Contract

Sample contract between physiotherapy staff and practice setting. Only PDF documents are accepted. One document per file upload.
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File Upload: Fees

Fee guideline or schedule. Only PDF documents are accepted. One document per file upload.
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File Upload: Infection Prevention and Control

Operational policies related to infection prevention and control. Only PDF documents are accepted. One document per file upload.
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File Upload: Patient Safety

Patient safety incident management plans. Only PDF documents are accepted. One document per file upload.
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File Upload: Privacy Impact Assessment

Include if practice setting has completed a Privacy Impact Assessment. Only PDF documents are accepted. One document per file upload.
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File Upload: Privacy Safeguards and Records Management

Operational policies related to privacy safeguards and records management. Only PDF documents are accepted. One document per file upload.
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File Upload: Privacy Statement

Practice setting privacy statement. Only PDF documents are accepted. One document per file upload.
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File Upload: Unregulated Health Providers

Operational policies regarding the use of unregulated health providers to deliver physiotherapy services if applicable. MUST include if practice setting employs support workers in the delivery of physiotherapy services. Only PDF documents are accepted. One document per file upload.
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Acknowledgements
As the Designated Owner, I agree to:
As the Designated Owner, I agree to:
As the Designated Owner, I agree to:
As the Designated Owner, I agree to:
As the Designated Owner, I agree to:
As the Designated Owner, I agree to:
As the Designated Owner, I agree to:
As the Designated Owner, I understand that:
As the Designated Owner, I certify and declare that:
Application Fee

A non-refundable $2,500 application fee is charged for reviewing and processing this application. The application fee is waived IF a previous application was approved with the same owner(s) and using the same supporting documents.
Is this an initial application for the owner(s) listed on this application? The $2,500.00 non-refundable application fee is waived IF a previous application was approved with the same owner(s) and using the same supporting documents. If the application fee applies, the College will provide email instructions for paying the fee online.
Submission
Submission Date

YearMonthDay
Designated Owner's Signature
Should be Empty:

Provision of Professional Services

Practice Setting Information

Social Media Profile

Ownership

Most Responsible Physiotherapist

Supporting Documents

Acknowledgements

Application Fee

Submission