Central Fabrication Accreditation Application Step 1 of 4 25% Central Fabrication Accreditation Application FormCentral Fabrication (non-patient care centers) will provide the following servicesCENTRAL 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 LOCATIONOrganization Name:(Required)Doing Business As (DBA)Primary Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Contact Name(Required) Full Name Phone(Required)Email(Required) Website Federal Tax ID ( GST ):Lab Established Date MM slash DD slash YYYY Number of labs:Please list any names the company works under: Add RemoveDOCUMENT 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 AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon 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 NamePercentage of Ownership Add Remove DAYS AND HOURS OF OPERATIONIndicate am/pmPlease input hours of operation (am - pm)MonTueWedThurFriSatSunClosed for Lunch? Yes No If yes, indicate timeHours by appointment only? Yes No If yes, indicate daysON - SITE ACCREDITATION CONTACT:Name of the individual(s) to be contacted reqarding this application and accreditation survey. Primary Contact Name(Required) Full Name Title Phone(Required)Email(Required) Secondary Contact Name Full Name Title PhoneEmail CERTIFIED / LICENSED INDIVIDUALS:List all clinical staff serving this location. Please attach a separate sheet if necessary. Clinical Staff Serving at this Location Full Name Credential Type Title Supervisor Yes No Clinical Staff Serving at this Location Full Name Credential Type Title Supervisor Yes No Upload separate list here if requiredMax. file size: 128 MB.Have you completed ICAPS/CAPS program? Yes No BILLING PERSONNEL:List all billing personnel. Please attach a separate sheet if necessary. Full Name Title Upload separate list here if requiredMax. file size: 128 MB.CRIMINAL HISTORY:Failure to respond will result in the application being returned. Failure to provide accurate, true and correct information shall constitute grounds for denial of your application, or removal of the credential.Has any owner or facility personnel ever been charged with a felony and plead guilty to, or been convicted of a lesser charge (i.e. misdemeanor)?(Required) Yes No Has any owner or facility personnel ever been prohibited from doing business with any division of the federal government or i s on the Office of the Inspector General’s (OIG) exclusion list?(Required) Yes No Has any owner or facility personnel ever been investigated by an insurance company?(Required) Yes No If yes, please note the result of this inspection and the insurance company who did the investigation: TERMS OF AGREEMENTThe 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. I understand that all fees associated with this application are non - refundable. 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 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. 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. I have liability insurance of $_______ 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. liability insurance of &(Required)Accepted by:(Required) First Last Organization Name(Required)Printed name of CEO or Authorized Personnel(Required)Signature(Required)Date(Required) MM slash DD slash YYYY Central Fabrication Accreditation – Payment FormThe following items must be included with your application:(Required) No less than 3 references NOT affiliated with the company Signed Ethical Code of Conduct Copy of ICAPS/CAPS (If applicable) Upload Required Files Drop files here or Select files Max. file size: 128 MB. Organization Name(Required)Doing Business As (DBA)(Required)CENTRAL FABRICATION TYPECheck 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 Central Fabrication Accreditation Fees (Fees are Subject to Change)Application Fee - $350 CAD | Survey Fee - $2150.00 CAD | Total Enclosed - $2500 CADPayment Options Credit Card Cheque Choose the following option for paymentApplication Fee Price: Survey Fee Price: Total Credit Card Billing Address(Required) Same as Primary Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code ChequePlease make your cheque payable to PFA Canada and send via mail to - 184 Sunset Drive, St. Thomas, ON, N5R 3B9 NameThis field is for validation purposes and should be left unchanged. Δ