APPLICATION FORM FOR RECOGNITION OF TRAINING AND CERTIFICATION OUTSIDE CANADA Physiciansapply.ca # or PCRC ID # CFPC Membership Number # CONTACT INFORMATION Family Name Given Names of Birth Gender Address Apt. No. or PO Box, Street No. and Name City Province Postal Code Country Office Telephone Home Telephone / Cell Email Fax PRIMARY MEDICAL QUALIFICATION If obtained at an institution outside of Canada, you must submit this credential to physiciansapply.ca for source verification. If obtained in Canada, you must submit a copy of your certificate with the application form. University / Medical School / College City Country Degree Obtained Graduation ACCREDITED FAMILY MEDICINE RESIDENCY / VOCATIONAL TRAINING PROGRAM You must submit this credential to physiciansapply.ca for source verification. Accredited by: ACGME RACGP ACRRM ICGP RCGP Name of ACGME Program / RTP / ICGP Program / Deanery City Country Degree Obtained s of Training Recognition of Training and Certification outside Canada Application Page 1
CERTIFICATION IN FAMILY MEDICINE You must submit this credential to physiciansapply.ca for source verification. Diplomate of ABFM Graduates of family medicine residency training programs that have been accredited by the Council of Graduate Medical Education (ACGME) and who are also Diplomates of the American Board of Family Medicine (ABFM) Fellow of RACGP Graduates of Australian General Practice Vocational Training programs that have been accredited by the Australian Medical Council (AMC) and meet the standards of the Royal Australian College of General Practitioners (RACGP) and who also hold Fellowship in the Royal Australian College of General Practitioners (FRACGP) Fellow of ACRRM Graduates of the Vocational Preparation Pathway (VPP) training program accredited by the Australian Medical Council (AMC) and administered through the Australian College of Rural and Remote Medicine (ACRRM) and who also hold the certification in family medicine leading to Fellowship of the Australian College of Rural and Remote Medicine (FACRRM) Member of ICGP Graduates of general practice vocational training schemes that have been accredited by Irish College of General Practitioners (ICGP) and who also hold Membership in the Irish College of General Practitioners (MICGP) Member of RCGP Graduates of general practice vocational training programmes that have been accredited by the General Medical Council (GMC) and who meet the standards of the Royal College of General Practitioners (RCGP) and who also hold Membership in the Royal College of General Practitioners (MRCGP) CANADIAN LICENSING INFORMATION Do you have a license to practice in Canada? Yes No All applications are subject to review by the Board of Examiners of the College of Family Physicians of Canada who will make final rulings on all questions of eligibility. Recognition of Training and Certification outside Canada Application Page 2
DECLARATION I declare that I am the true holder of the credentials detailed herewith and I authorize the College of Family Physicians to consult with other educational and licensing authorities to verify documentation submitted if necessary. Signature MAINTENANCE OF CERTIFICATION I will meet the requirements for continuing membership in the College of Family Physicians of Canada, and failing to do so, I understand that I forfeit the right to use the CCFP as part of my credentials. Signature Name (please print) The completed application should be sent to: Examinations and Credentials The College of Family Physicians of Canada 2630 Skymark Ave, Mississauga ON L4W 5A4 Email: ccfp_aeg@cfpc.ca Fax: 905-629-0893 Recognition of Training and Certification outside Canada Application Page 3
RELEASE & WAIVER I,, confirm and understand that the information that I have provided to The College of Family Physicians of Canada (the CFPC ) in this Application is true and authentic and will be verified and/or authenticated by the Medical Council of Canada (the MCC ) through its division the Physician Credentials Repository pursuant to an agreement between the CFPC and the MCC for credentialing to determine my eligibility for certification. I agree to hold harmless the CFPC, its officers, directors, shareholders, affiliates, associates, agents, employees, representatives, partners, volunteers, members, successors and assigns (the Released Parties ), with respect to the verification and authentication services provided to the CFPC by the MCC. Further, I, on my own behalf and on behalf of my heirs, executors, administrators, estate trustees, agents and assigns, hereby irrevocably release and forever discharge the Released Parties from any and all claims, demands, rights and causes of action of any kind whatsoever, which I now have or later may have, whether known or unknown, in any way resulting from the verification and authentication services provided to the CFPC by the MCC. I agree that this release and waiver shall be governed by the laws of the Province of Ontario. BY SIGNING THIS RELEASE AND WAIVER, I CERTIFY THAT I HAVE READ THIS RELEASE AND WAIVER FULLY AND UNDERSTAND IT. FURTHER, I HAVE NOT BEEN THREATENED OR PRESSURED IN ANY WAY TO SIGN THIS RELEASE. I AM OF SOUND LEGAL MIND AND NOT SUFFERING FROM ANY LEGAL DISABILITY. Applicant s Signature Applicant s Name Witness Signature Witness Name Recognition of Training and Certification outside Canada Application Page 4
REGISTERING YOUR CREDENTIALS WITH THE MEDICAL COUNCIL OF CANADA (MCC) PHYSICIAN CREDENTIALS REPOSITORY As part of the application process for recognition of training and certification outside Canada, you are required to register your credentials and supporting documents with the Physician Credentials Repository physiciansapply.ca (formerly known as PCRC). Physiciansapply.ca is responsible for obtaining primary source verification of the authenticity of your medical credentials from the institution that issued these documents to you. Please note: This process can take several months so the College recommends that you commence this process as soon as possible. Documents to submit for source verification The CFPC requires that you submit ONLY the three documents listed below. In order to avoid any unnecessary costs or delays, you should carefully read the following descriptions before submitting any documents to the physiciansapply.ca. After you have submitted all of your documents, you must ensure that you have shared your credentials with CFPC. This can be done by selecting Document Sharing once you have logged on to your physiciansapply.ca account. medical Degree (MD) or doctorate of osteopathy (DO) postgraduate family medicine training ABFM candidates must submit your postgraduate training certificate issued by the ACGME accredited family medicine training program confirming completion of training RACGP candidates must submit a document/certificate from the Regional Training Provider (RTP) which confirms the following: that you have successfully completed of all aspects of Australian General Practice Training as provided by (name of RTP) dates when you started and completed training with the RTP Australian General Practice Training meets the standards of the RACGP, which is accredited by the Australian Medical Council for education and training leading to Fellowship of the RACGP (FRACGP) ACRRM candidates must submit a document/certificate issued by the Regional Training Provider (RTP) which confirms That you have successfully completed all aspects of Australian General Practice Training as provided by (name of RTP) dates when you started and completed training with the RTP Australian General Practice Training meets the standards of the ACRRM, which is accredited by the Australian Medical Council for education and training leading to Fellowship of the ACRRM (FACRRM) MICGP candidates must submit a Certificate of Satisfactory Completion of Training (CSCT) issued by the ICGP accredited training program confirming completion of training. MRCGP candidates must submit a Certificate of Prescribed Experience from the JCPTGP OR a Certificate of Completion of Training (CCT) certification in family medicine DABFM, FRACGP, MICGP or MRCGP Recognition of Training and Certification outside Canada Application Page 5
Monitoring verification status The time it will take for documents to be verification returned passed depends on the issuing institutions. As the status of verification evolves, physiciansapply.ca will update your profile. You will be able to monitor the progress by logging in to your online account. You should monitor the status of your documentation and follow up with the relevant authorities to ensure timely verification. How to register with physiciansapply.ca MCC Support Desk Tel: (613) 520 2240 Fax: (613) 248 4234 Email: service@mcc.ca 1. Visit the physiciansapply.ca website Carefully read the description of the Source Verification Process and follow the detailed instructionshttp://mcc.ca/repository/submit-a-document/ 2. Please ensure that you have consented to share the applicable documents with the College of Family Physicians of Canada. Confirmation of application approval CFPC will notify you in writing when your documents have been approved. If, through monitoring your online physiciansapply.ca account, you note that all of your documents have reached the status verification returned passed, and you have not already received confirmation, you should notify the CFPC by e mail ccfp_aeg@cfpc.ca Recognition of Training and Certification outside Canada Application Page 6