Physician Application Form

Emergency Department Coverage Demonstration Project
163 Queen St. East
Toronto, ON M5A 1S1
Tel.: 1-800-596-4046 ext. 3
Fax: 1-866-535-2694
Email: [email protected]
www.HealthForceOntario.ca
Projet pilote de permanence des soins dans les services des urgences
163 Queen St. East
Toronto, ON M5A 1S1
Tel.:
1-800-596-4046 ext. 3
Fax:
1-866-535-2694
Email: [email protected]
www.professionssanteontario.ca
Emergency Department Coverage Demonstration Project (EDCDP)
Physician Application Form
About EDCDP
EDCDP is a provincial program designed to provide urgent ED locum coverage as an interim measure of last resort to
designated hospitals that are facing significant challenges covering ED physician shifts. EDCDP seeks to promote physicians
having stable, full-time commitments in Ontario EDs, while providing increased coverage capacity for these designated, highneed sites. When you work at an EDCDP hospital - be it in a small, rural, Northern, and/or regional referral site - you help
maintain ED services for an Ontarian community.
EDCDP was created in partnership by the Ontario Medical Association (OMA) and the Ministry of Health and Long-Term Care
(MOHLTC) as part of the government's ED Action Plan announced in October 2006. The HealthForceOntario Marketing and
Recruitment Agency (HFO MRA) developed and assumed responsibility for its implementation and ongoing operation. HFO
MRA continues to work together with system partners to support comprehensive and sustainable ED and HHR strategies.
Benefits of Locuming Through EDCDP
- Participate in one of three program streams, with varying levels of commitment/remuneration (details on pg.2)
- Link directly from our password-protected website to view and book shifts at different EDs across the province up to 30 days
in advance.
- Use our streamlined credentialing program (the Locum Credentialing Application Program), which enables physicians to
apply for privileges at multiple hospitals after completing only one set of credentialing documentation. More information
about the program can be found on our website.
- Choose where any when you work within the terms of your program stream, in a wide variety of hospital/community
settings, to assist where there is need.
Physician Acceptance Decisions
Acceptance is based on physician eligibility and program need, in accordance with our discretion.
Physician Eligibility:
- You must have either a or b:
a) CCFP (EM) or FRCP (EM) qualifications; OR
b) The equivalent of 1 year of full-time ED experience (with your independent practice license) within the last 3 years,
and current ATLS and ACLS training
- Physicians must work full-time in an ED in Ontario (maximum of 2 EDs), and must agree not to reduce their service
commitments to these home hospital(s).
- Preferential selection is given to physicians currently working full time in an ED in Ontario.
Last Updated: Oct, 2012
Program Need:
- At any given time, there are approximately 20 designated hospitals from across the province on the program, with a range
of start and end dates. Physician recruitment and renewal priorities are dynamic, as hospital participation/need varies, to best
suit overall program need.
Please note: Positions with EDCDP are limited. Physicians who meet eligibility requirements may be placed on a wait-list
based on program need.
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Emergency Department Coverage Demonstration Project
163 Queen St. East
Toronto, ON M5A 1S1
Tel.: 1-800-596-4046 ext. 3
Fax: 1-866-535-2694
Email: [email protected]
www.HealthForceOntario.ca
Projet pilote de permanence des soins dans les services des urgences
163 Queen St. East
Toronto, ON M5A 1S1
Tel.:
1-800-596-4046 ext. 3
Fax:
1-866-535-2694
Email: [email protected]
www.professionssanteontario.ca
Emergency Department Coverage Demonstration Project (EDCDP)
Physician Application Form
EDCDP Hospitals
- To qualify for the program, hospitals must demonstrate relative highest need for ED coverage assistance
- Eligible hospitals are given limited terms of participation, and are continually reviewed against relative need for extension/
conclusion
- Hospitals can range from rural/remote to regional referral centre, with a focus on single-coverage shifts
EDCDP Program Streams
1. FIXED PROGRAM
(a) Provincial
- Provide coverage at any EDCDP hospital in the province
- Minimum commitment of 60 hours per three month period
- Receive a monthly stipend of $3000.
- Available in 3-month or 6-month contracts
2. FLEXIBLE PROGRAM
(a) LHIN
- Provide coverage at designated EDCDP hospitals within the physician's home LHIN (or as determined by EDCDP)
- Minimum commitment of one shift per three months
- Receive an hourly stipend of $120
- The ED LHIN Lead determines any additional physician parameters
(b) Provincial
- Provide coverage at any EDCDP hospital in the province
- Minimum commitment of one shift per three months
- No stipend
All EDCDP physicians receive:
- Travel time reimbursement from the program: Travel time greater than 2 hours one-way will be reimbursed at a rate of
$300. Travel time greater than 4 hours one-way will be reimbursed at a rate of $600.
- Reasonable travel and accommodation cost reimbursement from hospitals (as determined by individual hospital policies)
- Compensation from hospitals: pay for actual hours worked at the applicable ED AFA (alternative funding agreement) or FFS
(fee for service) rates
How To Apply
Last Updated: Oct, 2012
Please review and complete pages 3-5 and return them by:
· Email at: [email protected]
· Fax at: 416-874-4075 (local) or 1-866-535-2694 (toll-free)
For More Information
Please visit our website at http://www.healthforceontario.ca/Jobs/OntarioPhysicianLocumPrograms/
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Emergency Department Coverage Demonstration Project
163 Queen St. East
Toronto, ON M5A 1S1
Tel.: 1-800-596-4046 ext. 3
Fax: 1-866-535-2694
Email: [email protected]
www.HealthForceOntario.ca
Projet pilote de permanence des soins dans les services des urgences
163 Queen St. East
Toronto, ON M5A 1S1
Tel.:
1-800-596-4046 ext. 3
Fax:
1-866-535-2694
Email: [email protected]
www.professionssanteontario.ca
Emergency Department Coverage Demonstration Project (EDCDP)
Physician Application Form
Personal Information:
please print clearly
First Name
Home Phone
Last Name
Mobile Phone
Office/Business Phone
Fax
Address
Email
How were you introduced to EDCDP? Optional and check all that apply
HFO MRA Web site
Other _____________________
Professional/Recruiting Event
Colleague (Please specify so we can extend appreciation)
Which program are you applying to? Check all that apply
Fixed - Provincial
minimum 60 hours/3 months
Flexible - LHIN
minimum 1 shift/3 months
Flexible - Provincial
minimum 1 shift/3 months
Home LHIN:
Month:
When would you be available to start?
Year:
Last Updated: Oct, 2012
Certifications: Check all that apply
Yes FRCP (EM)
No Year:
Yes CCFP
No Year:
Yes ACLS
No Year:
Yes CCFP (EM)
No Year:
Yes PALS
No Year:
Yes ATLS
No Year:
Are you able to provide medical services in French?
Initials
Yes
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No
Emergency Department Coverage Demonstration Project
163 Queen St. East
Toronto, ON M5A 1S1
Tel.: 1-800-596-4046 ext. 3
Fax: 1-866-535-2694
Email: [email protected]
www.HealthForceOntario.ca
Projet pilote de permanence des soins dans les services des urgences
163 Queen St. East
Toronto, ON M5A 1S1
Tel.:
1-800-596-4046 ext. 3
Fax:
1-866-535-2694
Email: [email protected]
www.professionssanteontario.ca
Emergency Department Coverage Demonstration Project (EDCDP)
Physician Application Form
ED Experience:
Have you worked in an ED on a full-time basis for a total of 12 months
during the past 3 years as an independently licensed physician?
Ability to work on your own in:
Check all that apply
Yes
No
Rural (some local backup)
Urban (with trauma centre)
Rural (no local backup)
Urban (without trauma centre)
Comments:
Hospital Information: Please list all hospitals in which you have provided ED coverage in the past THREE years
(please attach separate page if required)
1. Hospital Site
City
Province/Country
2. Hospital Site
City/Town/Community
Province/Country
3. Hospital Site
City/Town/Community
Province/Country
Last Updated: Oct, 2012
4. Hospital Site
City/Town/Community
Province/Country
Initials
Dates of Appointment (month/year)
From
To
How many hours of coverage do
provide in a typical week (on average)?
Dates of Appointment (month/year)
From
To
How many hours of coverage do
provide in a typical week (on average)?
Dates of Appointment (month/year)
From
To
How many hours of coverage do
provide in a typical week (on average)?
Dates of Appointment (month/year)
From
To
How many hours of coverage do
provide in a typical week (on average)?
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Emergency Department Coverage Demonstration Project
163 Queen St. East
Toronto, ON M5A 1S1
Tel.: 1-800-596-4046 ext. 3
Fax: 1-866-535-2694
Email: [email protected]
www.HealthForceOntario.ca
Projet pilote de permanence des soins dans les services des urgences
163 Queen St. East
Toronto, ON M5A 1S1
Tel.:
1-800-596-4046 ext. 3
Fax:
1-866-535-2694
Email: [email protected]
www.professionssanteontario.ca
Emergency Department Coverage Demonstration Project (EDCDP)
Physician Application Form
Home Hospital Service Commitment:
Please outline your anticipated service commitments (average number of hours worked per week) to your Ontario home hospital ED(s)
for the next 12 months
Hospital
Average hrs/wk
Hospital
Average hrs/wk
Hospital
Average hrs/wk
Comments:
Professional Information:
CPSO NUMBER
Any restrictions?
Date Issued:
Yes
No
If yes, please describe
CMPA Number
Date Issued:
OHIP Billing Number
Date Issued:
Application Confirmation:
I confirm that the information I have provided is accurate and up-to-date, to the best of my knowledge.
Signature:
Date Signed:
Last Updated: Oct, 2012
Thank you for your interest in EDCDP.
Please return your completed application to the attention of the EDCDP Team by
fax: 416-874-4075 (local) or 1-866-535-2694 (toll-free)
email: [email protected]
Notice of Collection: HealthForceOntario Marketing and Recruitment Agency collects your personal information under the authority of the Development Corporations Act,
Ontario Regulation 249/07, section 3. All information collected on this form may be used as necessary by HealthForceOntario Marketing and Recruitment Agency for the
proper administration of the government-funded Recruitment and Retention Programs, including assessing your eligibility to participate in and receive payment from these
programs. The information on this form may also be used by HealthForceOntario Marketing and Recruitment Agency and/or the Ministry of Health and Long-Term Care for the
proper financial administration of these programs, and for conducting research and evaluating program parameters. If you require further information about the collection by
HealthForceOntario Marketing and Recruitment Agency, please contact: the information coordinator at HealthForceOntario Marketing and Recruitment Agency at 163 Queen
Street East, Toronto, ON M5A 1S1, or 416-862-2200 / 1-800-463-1270. If you require further information about the collection by the Ministry please contact: the Director of
the Health Sector Labour Market Policy Branch, Health Human Resources Strategy Division, Ministry of Health and Long-Term Care at 56 Wellesley Street West, 12th Floor,
Toronto, ON M5S 2S3, or 416-212-0873.
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