Central Fabrication Accreditation Application

Central Fabrication Accreditation Application Form

Central Fabrication (non-patient care centers) will provide the following services

CENTRAL FABRICATION TYPE :(Required)

Check all that apply

Orthotic (includes Pedorthic)

Pedorthic (only below ankle items/devices)

For this business only

For Other Businesses

For both this business and others

PRIMARY LOCATION

Organization Name:(Required)

Doing Business As (DBA)

Primary Address(Required)

Street Address Address Line 2 City Province Postal Code

Contact Name(Required)

Full Name

Phone(Required)

Email(Required)

Website

Federal Tax ID ( GST ):

Lab Established Date

Number of labs:

Please list any names the company works under:

DOCUMENT LOCATION:

Please select one.

Records are housed at primary location listed above

Records are housed at a different location. Records are kept at the following location

Document Address

Street Address Address Line 2 City Province Postal Code

Documentation at this location:

Personnel Files

Clinical Records

Financial/Billing

Customer Satisfaction Surveys

OWNERSHIP INFORMATION:(Required)

List all individuals holding more than 5% of company shares or provide a current list of your Central Fabrication’s Board of Directors or Trustees. Please attach a separate sheet if necessary.

Owner Name

Percentage of Ownership

TERMS OF AGREEMENT

The undersigned Organization makes application to the Pedorthic Foot care Association - Canadian Chapter for voluntary accreditation of the Organization and certifies that the information recorded in this application and attachments is true and correct. The Organization agrees, at all times, to provide information requested by PFA relevant to the review, evaluation and maintenance of the Organization’s accreditation status. Information obtained or generated bt PFA in the accreditation process is for the purpose of reviewing the professional service of the Organization. PFA acknowledges that the information obtained or generated by PFA shall be considered confidential between the Organization and PFA, and shall be treated on a confidential basis, except as otherwise provided in PFA’s policies or as required by law, a court of law, or a governmental agency. PFA will not take possession of any private health information about which it becomes aware during the course of PFA’s investigation of this application. The Organization agrees that, if accredited, it will remain in compliance with PFA’s accreditation standards and that failure to do so may result in loss of PFA accreditation status. The Organization is responsible for immediately being in compliance with existing, new and/or modified accreditation standards, as and when they are adopted by PFA. The Organization agrees to abide by and be bound by the PFA Code of Professional Responsibility & Rules and Procedures and as they may be modified by PFA Canada. The Organization’s failure to abide by these terms and conditions may result in sanctions, including loss of accreditation status, against the Organization.

By initializing and signing my name below, I agree to the following statements:

(Required)

I have read the Terms of Agreement section above.(Required)

I have read the Terms of Agreement section above.

I understand that my organization must notify PFA Canada in writing within 30 days of all changes in ownership, corporate structure, location, personnel and/or provision of items/devices. Some changes may require submitting a new application, survey and applicable fees.(Required)

I understand that my organization must notify PFA Canada in writing within 30 days of all changes in ownership, corporate structure, location, personnel and/or provision of items/devices. Some changes may require submitting a new application, survey and applicable fees.

I understand that all fees associated with this application are non - refundable.(Required)

I understand that all fees associated with this application are non - refundable.

I understand that this lab will be listed on PFA’s website, with a picture of the owner outside the establishment, along with all current information – address must be current at all times.(Required)

I understand that this lab will be listed on PFA’s website, with a picture of the owner outside the establishment, along with all current information – address must be current at all times.

I understand that all insurance inspections and outcomes must be reported to PFA Canada within 5 days.(Required)

I understand that all insurance inspections and outcomes must be reported to PFA Canada within 5 days.

I agree to random inspections(Required)

I agree to random inspections

I agree to have a C. Ped., C. Ped. (C), BOCPD, or C. Ped. Tech. (C) overseeing the manufacturing of the orthotics, at all times.(Required)

I agree to have a C. Ped., C. Ped. (C), BOCPD, or C. Ped. Tech. (C) overseeing the manufacturing of the orthotics, at all times.

I have liability insurance of $______(Required)

I have liability insurance of $______

Liability insurance of $(Required)

I attest that all information reported on this application is complete, accurate and true to the best of my knowledge. I understand that falsification of information may result in a revocation of accreditation.(Required)

I attest that all information reported on this application is complete, accurate and true to the best of my knowledge. I understand that falsification of information may result in a revocation of accreditation.

Accepted by:(Required)

First Last

Organization Name(Required)

Printed name of CEO or Authorized Personnel(Required)

Signature(Required)

Date