MVA IMC Roster Application MVA IMC Roster Application Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Practice Permit Number:(Required)Declaration StatementsConsent(Required) I understand and agree to work according to the diagnostic and treatment protocols outlined in the Insurance Act, Diagnostic and Treatment Protocols Regulation when applicable to the injured individual.(Required)Consent(Required) I have a working knowledge of the biopsychosocial model as described in the International Classification of Functioning, Disability and Health.(Required)Consent(Required) I am prepared to assess and quantify acute/chronic pain.(Required)Consent(Required) I have experience working with and managing the rehabilitation of MVA patients and use current research evidence in practice.(Required)Consent(Required) I am prepared to demonstrate ongoing knowledge of best practices either via literature review/research paper or by attending educational sessions directly related to treatment of MVA injuries and their related outcomes. This demonstration of knowledge will be presented as part of my continuing competence program requirements at least once every five years.(Required)Signature(Required)Date signed:(Required) MM slash DD slash YYYY Questions? Please feel free to contact registration@theccoa.ca.
