Annual Licence Renewal Form 2011 - TUUM EST

2011 ANNUAL LICENSE RENEWAL FEE:
Received on or before 4:00 pm (AST) on January 6,
2011 - $1,555.00
Received after 4:00 pm (AST) on January 6, 2011 -
$1,860.00
ANNUAL LICENSE RENEWAL – 2011
Received after 4:00 pm (AST) on January 31, 2011 -
$2,060.00 (Reinstatement Fee)
If you are unable to locate your personalized license renewal form
please print this form, complete it and return it with your payment.
Surname: _____________________________________
REGISTRATION NO : _______________
Given Name(s): ________________________________
If you do not wish to renew your license in Nova Scotia as of January 1, 2011 please check the box to
the left, sign and date this form and return it to the College.
A. MISCELLANEOUS:
1. The College distributes its member publications (newsletter, physician guidelines and policies, annual report)
by e-mail and fax only. These documents are also available on the College website (www.cpsns.ns.ca) or upon
request.
Would you prefer to receive publications by (select one or both):
E-mail __________________________________@__________________________________
Fax
__________________________________________________ (to receive member publications only)
(please include area code and where applicable, country code)
B. ADDRESS INFORMATION:
Office Address (Public Information):
Company/Hospital:
Address 1:
Address 2:
City/Province:
Postal Code:
County:
Country:
Phone:
Fax:
District Health
Authority:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
(_____)______________________________________________
(_____)______________________________________________
____________________________________________________
Home Mailing Address (College use only):
Additional Info:
Address 1:
Address 2:
City/Province:
Postal Code:
County
Country:
Phone:
Fax:
District Health
Authority:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
(_____)______________________________________________
(_____)______________________________________________
____________________________________________________
Preferred address for receipt of College correspondence (choose one):
If you have a hospital-based practice you may prefer to use your home address for College correspondence.
OFFICE or HOME
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C. QUESTIONS: It is mandatory that you answer the following questions.
THE FOLLOWING QUESTIONS REFER TO THE LAST 12 MONTHS:
1. Have you been disciplined or are there any complaints or disciplinary actions pending against you by any licensing YES NO
authority other than the College of Physicians and Surgeons of Nova Scotia
2. Have you had any conditions or restrictions placed on your license by any licensing authority YES NO
3. Have you entered into a settlement agreement or voluntary undertaking with any licensing authority YES NO
4. Are there any criminal charges pending against you or have you pleaded guilty to or been convicted of a criminal YES NO
offence in or out of Canada
5. Are there any charges pending against you or have you pleaded guilty to or been convicted of an offence for the YES NO
improper prescribing of controlled substances in or out of Canada
6. Have you been found liable in any court of competent jurisdiction as a result of a breach of the standard of care or YES NO
professional misconduct with respect to your practice
7. Have you had your privileges to practice in a hospital or regional health authority revoked, withdrawn, altered in YES NO
any way or not renewed as a result of professional or personal conduct or competence/concerns
8. Have you resigned your hospital privileges while under investigation in respect of such a matter YES NO
9. Have you become seropositive for a blood borne viral pathogen such as Hepatitis B, Hepatitis C or HIV YES NO
10. Do you have a condition that may limit your ability to practice or constitute a risk to patients YES NO
11. Are you abusing, dependent on, or addicted to alcohol or a drug YES NO
12. Are you being or have you been treated for abuse of, dependence on, or addiction to alcohol or a drug YES NO
13. Have you been absent from the practice of medicine for three (3) or more years YES NO
If you answered YES to any of the questions above please promptly provide details in a PERSONAL & CONFIDENTIAL letter to
the Deputy Registrar of Registration of the College of Physicians and Surgeons of Nova Scotia in order to complete your renewal.
D. NOVA SCOTIA PHYSICIAN ACHIEVEMENT REVIEW (NSPAR): NSPAR 2011
It is mandatory that you answer the following questions.
NSPAR is the peer assessment program of the College. It is mandatory for all eligible physicians to complete the NSPAR process at
least once every seven years.
Circle One
1. Are you fully retired from clinical practice
YES
NO
If you answered ‘no’ to Question 1, please go directly to Question 3. If your answer to Question 1 was ‘yes’, please
complete Questions 2 and 2(a).
2. Do you plan to return to clinical practice at some point in the future YES NO
2(a) If yes, when do you plan to return to clinical practice Month _____________ Year ________
Unknown
3. What percentage of your working time do you spend on each of the following (Please record all that apply and ensure the
percentages total 100%).
Practicing as a family physician
Practicing primary care mental health
Practicing as a specialist
Doing episodic care (eg. emergency
medicine, walk-in clinics, palliative care,
or locum coverage)
Working in a non-clinical capacity
(eg. administration, public health, doing
research)
___________%
___________%
___________%
___________%
___________%
If you are practicing a specialty, please record
the specialty that you currently spend the
majority of your time practicing.
______________________________________
(name of specialty)
Is this a Pediatric specialty That is, do
you practice your specialty predominantly with
children under the age of 16 years (eg.
Pediatrics, Pediatric Cardiology, Pediatric
Oncology)
Other (please specify): ___________________
___________%
YES
NO
TOTAL MUST EQUAL 100 %
E. EMERGENCY PREPAREDNESS:
The College is assembling a list of names and secure contact information of members who would be willing and available to
provide care during a significant health emergency. This information may also be provided to the Joint Health Emergency Operations
Centre (JHEOC) of the Department of Health/Health Promotion and Protection if required. This information will not be released
in any other way than specified above. Please indicate below if you would like to have your name and contact information placed on
this list.
YES
NO
_____________________ and/or ______________________________ and/or ____________________________
Celllular phone # E-mail Fax #
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F. DECLARATION:
IMPORTANT!
PLEASE SIGN AND DATE BELOW EVEN IF THERE ARE NO CHANGES TO THE ABOVE INFORMATION
I affirm that, to the best of my knowledge, the information contained in this annual license renewal form is true and
accurate. I understand that information contained on this form will be used by the College for registration and
licensing purposes. The information contained on this form, with the exception of Section C, will also be used for the
NSPAR program. Knowingly providing false information on this renewal form may constitute professional misconduct.
______________________________________
Physician’s Signature
____________________________________
Date
MEMBERSHIP CARDS AND TAX RECEIPTS WILL BE ISSUED ONLY UPON RECEIPT OF YOUR PAYMENT
AND COMPLETED AND SIGNED ANNUAL LICENSE RENEWAL FORM.
G. PAYMENT OF FEES FOR 2010:
(Payment options: Cash, Cheque, Money Order, VISA, American Express or Master Card)
Received on or before 4:00 pm (AST) on January 6, 2011 - $1,555 .00
Received after 4:00 pm (AST) on January 6, 2011 - $1,860.00
Received after 4:00 pm (AST) on January 31, 2011 - $2,060.00 (Reinstatement Fee)
VISA, AMERICAN EXPRESS, MASTERCARD only
Cardholder: ______________________________________________
Card Number: ____________________________________________
There is a $55.00 administration fee for all
cheques returned by the bank for nonprocessing.
Replacement payments must be
made by money order, certified cheque or cash
and include the $55.00 administration fee.
Expiry Date: ______________________________________________
Please return all pages of your completed form and payment to:
COLLEGE OF PHYSICIANS & SURGEONS OF NOVA SCOTIA
5005 – 7071 BAYERS ROAD, HALIFAX, NS B3l
Phone: (902) 422-5823 Fax: (902) 422-5035
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