Registration Request

Important: This form takes approximately 10 minutes to complete. The system does not save your progress. You must complete and submit your request in a single session.

Overview

The Ministries of Hospital and Surgical Health Services and Primary and Preventative Health Services have put safeguards and eligibility criteria in place for the Dual Practice model to protect access to the public health system and prioritize patient safety. This includes restrictions on which physicians can participate and which surgeries can be provided privately, requirements for physicians to continue providing care in the public system, and ongoing monitoring of public and private surgical activity. Surgeries for life-threatening conditions, as well as emergency and urgent procedures, will remain entirely publicly funded.

More information is available on the Government of Alberta and Acute Care Alberta websites:

Eligibility Requirements

The following items are required to apply for Dual Practice:

Active Practitioner ID issued by Primary and Preventative Health Services;
Professional College practice permit number; and
Enrolled as participating physicians in the Alberta Health Care Insurance Plan

Please note that Participation in Dual Practice is restricted for:

AMHSP members
Non-Surgical Provider (defined as consulting specialty providers who do not perform eligible procedures or surgeries)

Are you an AMHSP member or a Non-Surgical Provider?

Yes

You are not eligible to participate in Dual Practice. Please click this link to review eligibility requirements. Alberta Dual Practice Program - Acute Care Alberta

If you have questions about the collection, use, or disclosure of this information, please contact SCA.DualPracticeProgram@acutecarealberta.ca

Physician Information

Practitioner ID (PRAC ID)

PRAC ID is required (numbers only)

First Name

First name is required

Last Name

Last name is required

Email Address

Enter a valid email address (e.g., name@example.com)

Primary Phone Number

Please enter a valid 10-digit phone number (numbers only)

Work Phone Number

Please enter a valid 10-digit phone number (numbers only)

Address

Address is required

Address 2

City

City is required

Province

Province is required

Postal Code

Please enter a valid postal code (e.g., T2X 1V4)

Professional College Registration Status

Please select your professional college under the Alberta Federation of Regulated Health Professions

Professional College

Professional College is required

Practice permit number

Practice permit number is required

Current Practice Profile

Primary hospital site (if applicable)

What is your current FTE? Please enter a value between 0.0 and 1.0

Clinical Discipline

Clinical discipline is required

Clinical Specialty

Clinical specialty cannot be 'Not Applicable' when clinical discipline is {{ getDisciplineNameById(1) }}

Proposed Dual Practice Model

Choose all proposed procedures you are interested in performing as a flexibly participating provider (non-insured procedures) Learn more

Please select at least one procedure

Proposed corridors (if known) Learn more

Proposed private surgical facility/chartered (if applicable)

Review and submit your proposed Dual Practice model

Check the details below, then submit to finish.

Procedures

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No procedure(s) selected

Corridors

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No corridor(s) selected

Facilities

Privacy

Your personal information is collected by Acute Care Alberta (ACA) under S. 4(c) of the Protection of Privacy Act (POPA) for the administration of the Alberta Dual Practice Program. Your information will be used and disclosed as authorized by POPA, including for the review and processing of your application by ACA and for sharing the outcome with the Ministry of Primary and Preventative Health Services (PPHS) responsible for Flexible Participating Physician approvals. Your information will continue to be shared between ACA, the Ministry of Hospital and Surgical Health Services (HSHS) and PPHS for program administration, evaluation, and compliance monitoring purposes. If your application is approved, your name and business information will be published on the ACA website as part of the list of approved Flexible Participating Physicians.

I Agree.

You must agree before you can submit.

Statement of Acknowledgement

I certify that the information provided in the DPP Registration Request Form is true, complete, and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of information may result in disqualification from consideration for Dual Practice. I authorize the verification of any or all information listed above.

I have read the mandatory requirements for participation in the Alberta Dual Practice Model and understand that additional requirements and application may need to be met in order to participate in the program.

I acknowledge that I have read and understood the collection notice above. I understand that my personal information is collected by Acute Care Alberta to support my Flexible Participating Physician application process and will be used and disclosed as authorized under Protection of Privacy Act to support decision-making, to administer, evaluate, and monitor compliance with Dual Practice, and if approved, to publish my name and business information as part of the list of approved Flexible Participating Physicians.