Emergency Physician Resource Team - Expression of Interest

Provincial Emergency Physician Resource Team
Expression of Interest

Thank you for your interest in the Provincial Emergency Physician Resource Team.

Please fill out this form to begin the process:
Expect a response within 3 business days on next steps, including a copy of the retainer agreement for your review and signature.

Personal Information

*Full Legal Name

*Date of Birth

*Home Address

*Preferred Email Address

Phone Number (Including Area Code)

Professional Information

Are you incorporated? If yes, incorporated name:

*Level of Certification

	CCFP (EM)
	FRCPC EM
	Other Relevant Qualification

*Do you have a full staff medical appointment (provisional or active)?
If yes, in which health authority(s) and which site(s)?

	No
	Yes

Indicate the Health Authorities where you currently have privileges.

	FHA
	IH
	NH
	VCH/PHC
	VIHA

Please confirm what Electronic Medical Records (EMR) you have experience with:

	Meditech
	Meditech Client Server
	Meditech Expanse
	Cerner
	Cerner-Powerchart
	Cerner-Powercart/EDIS
	MOIS
	Other:

Consent

*I give permission to ECBC to access my information on the provincial credentialing and privileging system (CACTUS) to verify my eligibility for the Provincial Emergency Physician Resource Team.

I CONSENT

**I give permission to IH, NH, VIHA, FH, VCH/PHC, PHSA, FNHA to access my information on the provincial credentialing and privileging system (CACTUS) and/or to contact the C&P staff of my home Health Authority to credential and privilege me to participate in shift coverage across B.C. as part the Provincial Emergency Physician Resource Team.

I CONSENT

*I give permission to ECBC to contact me with regular updates and shift opportunities.

I CONSENT