Government of Ontario: Ministry of Health and Long-Term Care

Application for Physician Locum Programs

Please return signed copies to:
Primary Health Care Team
Underserviced Area Program
159 Cedar Street, Suite 402
Sudbury ON P3E 6A5
Telephone: 705 564-7280
Toll free: 1 866 727-9959

Personal Information
Surname

Given names

Practice address
Practice Address

Postal code

Telephone number ( ) –

E–mail address

Home address
Home Address

Postal code

Telephone number ( ) –

Please check one of the following:

I prefer to communicate in English
I prefer to communicate in French
I prefer to communicate by E–mail

Please check one of the following:

General/Family Practitioner
Psychiatrist
Specialist (indicate specialty)

The following documents are also required:

A copy of Ontario Certificate of Registration
A copy of your CCFP, or RCPSC certificate
Proof of CMPA
Proof of hospital priviledges.

Statement under the Freedom of Information and Protection of Privacy Act
The Ministry of Health and Long-Term Care is authorized to collect the personal information requested in this form for the purpose of properly administering the Ministry’s Physician Programs under subsection 6(1) paragraph 4 or clause 6(2)(b) of the Ministry of Health and Long-Term Care Act, R.S.O. 1990, c. M. 26. The personal information will be used to assess, verify and monitor eligibility for participation in the Physician Program and for payment. For information about this collection, please contact Manager, Underserviced Area Program, at 159 Cedar Street, Suite 402, Sudbury ON P3E 6A5, telephone no. 705 564-7280 or 1 866 727-9959.

Consent
I agree to cooperate fully with the Ministry of Health and Long-Term Care, Underserviced Area Program, or its agents, in any evaluation of the program by the branch. Furthermore, I consent to the disclosure of my personal information, contained in any Ministry of Health and Long-Term Care files pertaining to the Underserviced Area Program, to the Branch or its agents for the purposes of evaluation of the Program, and to hospitals, clinics or other health care facilities in Ministry-approved underserviced communities, as well as to agents of such communities for the purpose of recruitment.

Signature

Date YYYY MM DD