P.O. BOX 2415 - WCB Alberta



298454401900P.O. BOX 2415EDMONTON, AB T5J 2S5FAX: 780-498-3998780-498-3219ACUPUNCTURE SERVICESNew Provider ApplicationPROVIDER INFORMATION Date: FORMTEXT ????? FORMCHECKBOX Registered Acupuncturist FORMCHECKBOX Physical Therapist FORMCHECKBOX Chiropractor FORMCHECKBOX PhysicianName of Applicant FORMTEXT ?????Clinic Name FORMTEXT ?????Email Address FORMTEXT ?????Phone Number FORMTEXT ?????Fax Number FORMTEXT ?????Business Address Street FORMTEXT ?????City FORMTEXT ?????Province FORMTEXT ?????Postal Code FORMTEXT ?????Correspondence and cheques should be sent to FORMCHECKBOX Address above, orName FORMTEXT ?????Address FORMTEXT ?????PLEASE SUBMITProof of Acupuncture Registration FORMCHECKBOX College and Association of Acupuncturists of Alberta (CAAA) FORMCHECKBOX Physiotherapy Alberta – College + Association (PACA) FORMCHECKBOX College of Physicians & Surgeons (CPSA) FORMCHECKBOX Alberta College & Association of Chiropractors (ACAC)Proof of Professional Liability Insurance FORMCHECKBOX The Provider shall maintain Professional Liability Insurance in an amount not less than TWO MILLION ($2,000,000.00) DOLLARS per occurrence.Proof of Clinic Comprehensive or General Insurance FORMCHECKBOX The Provider shall insure his operations under a contract of General Liability Insurance, in accordance with Alberta Insurance Act, in an amount not less than TWO MILLION ($2,000,000.00) per occurrence.Submit completed application to hcs.ba@wcb.ab.ca ................
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