Physician Affiliation Authorization and Declaration of Professional Standing for ICHSCs

The form is used to confirm a physician's qualifications to provide the requested services prior to processing a request to affiliate to a particular ICHSC. The licensee must ensure that the physician has been affiliated to the centre before they begin to provide licensed services.

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Form Number 014-4900-85
Title Physician Affiliation Authorization and Declaration of Professional Standing for ICHSCs
Description The form is used to confirm a physician's qualifications to provide the requested services prior to processing a request to affiliate to a particular ICHSC. The licensee must ensure that the physician has been affiliated to the centre before they begin to provide licensed services.