Palliative Care Facilitated Access

PCFA NP PRESCRIBER REGISTRATION - APPLICATION FORM

Date

Full Name *

Work Email *

Personal Email *

Phone *

NP Credentials *

CNO Certificate and Number *

NP OHIP Billing Number *

Employer *

Employer Address *

Employer Address

City

State/Province

Zip/Postal

Country

Employer Contact Number *

Job Title *

Job Description

Maximum file size: 516MB

Evidence of Palliative / End-of-Life Care Continuing Education (e.g., Pallium - LEAP, de Souza Institute, etc.)

Maximum file size: 516MB

Attach certificate(s), or other evidence to demonstrate successful completion, currency of certificate/ education, etc.)

Course Name

Date Completed

Expiry Date

Additionally, an NP must also meet at least one of the following criteria. Please check all that apply *

Provide 20 or more palliative care consults or assessments within a year

Provide 30 – 50 or more palliative care visits within a year

Have been identified by the NP’s employer as an NP provider of palliative care

Work in collaboration with a Palliative Care Physician or PCFA approved NP (Provide name and contact information)

PCFA Approved NP Full Name

PCFA Approved NP Phone Number

Additional Supporting Documentation

Maximum file size: 2MB

PCFA Renewal

I am renewing my PCFA Application

If you are human, leave this field blank.

An NP who wishes to be added to the PCFA prescriber list must:

Hold current certification in the extended class [RN(EC)] with CNO;
Be authorized to prescribe controlled drugs and substances;
Have no restrictions on the NP certification that impact ability to practice; and
Provide evidence of continuing education in palliative and end-of-life care.

Become a part of this vibrant, dynamic organization!