Nurse Practitioner's Association of Ontario | Palliative Care Facilitated Access

Full Name *

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 *

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Maximum upload size: 8.39MB

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

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Maximum upload size: 8.39MB

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

Course Name

Date Completed

Expiry Date

Necessary Criteria *

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

Resource Centre