Certified Examiners Application Form - College of Dental Surgeons of Alberta

Apply for Certified Examiner Approval

Certified Examiners are designated dentists not involved in the patient’s care who perform independent dental assessments and provide third party expert opinions in regard to injuries covered by Minor Injury Regulations under Alberta’s Insurance Act. The Superintendent of Insurance will make the final determination as to whose names will be added to or remain on the official list of Certified Examiners. The list is posted on the Alberta Government’s Department of Finance website. Therefore, please ensure the contact information you provide below is information you would want published.

Personal Identification

ADA&C Unique Identification Number*

Business Phone*

Business Fax

Type of Practice*

Declarations

Please describe formal training to conduct IMEs.*

How many IMEs have you done in the past three (3) years?*

Signature

The ADA&C collects this information pursuant to the Minor Injury Regulation of the Insurance Act. Information in this form may be reviewed by the ADA&C to verify that an applicant meets the requirements set out in Division 2 of that Regulation, and may be disclosed to the Superintendent appointed under the Insurance Act (Alberta). The ADA&C will also notify the Superintendent if a dentist who has been recognized as a Certified Examiner ceases to meet the requirements of this Regulation.

Date*