Application to Change Status to Non-Practicing

Application to Change Registration Status to Non-Practicing

Regulated Chiropractor Information

Name(Required)

Forwarding Address

Address(Required)

Designate a Custodian to Retain and Provide Access to your Patient Records

  • The Health Information Act requires that all patient files be in the care and control of an authorized custodian. A custodian must be an actively registered regulated health care provider as defined in the Health Professions Act and Health Information Act. An CCOA member who is no longer active cannot be a custodian.
  • You must identify an appropriate arrangement with an authorized custodian prior to changing your status. This transfer should be documented, signed, and retained by both parties.
  • It is illegal to retain the files yourself once you are no longer an active member of the CCOA.
Custodian Name(Required)
Address(Required)

Understandings and Consent

Consent(Required)
Consent(Required)
Consent(Required)
Consent(Required)
Consent(Required)
Consent(Required)
Clear Signature
MM slash DD slash YYYY

Questions?

Please feel free to contact registration@theccoa.ca.