Forms

The below list includes the various Blended Capitation Program forms you may need to complete as you apply to or participate in the Model.

All forms can be completed online to make the process as straightforward and efficient as possible.  The forms are designed to minimize administrative burden while ensuring all necessary information is captured accurately.

Should you have any questions or require assistance with any of the forms, please contact Jason Clarke at FPRP (jclarke@nlma.nl.ca).

Expression of Interest Form

Family physicians, who are interested in participating in the Blended Capitation program, must submit an expression of interest. At this point, the intent is to capture interested physician names and contact information, to facilitate follow-up at a later date. Please note this form is an expression of interest only and represents an ongoing process—there is no deadline for submission.  To submit your expression of interest, please complete the form below.

Expression of Interest Form

After Hours Exemption Form

For the first two years of the program, groups that already provide regular, ongoing provision of services to the NL Health Services, such as hospitalist services, primary care services for unattached patients, hospital emergency room coverage, anesthesia services, obstetric services, and long-term care services, will be permitted to redistribute their after-hours service obligations to the Group’s nurse practitioner (NP) or, if the Group has not hired an NP, to seek an exemption from the Blended Capitation after-hours requirement.

Groups may apply to the FPRP to determine if members of the group qualify for exemption by completing this form.  For a physician to qualify, they must be providing at least two hours of the types of services described above to NLHS for every one hour of after-hours BCM service exempted or redistributed.  Groups that do not provide any of the types of services outlined above do not qualify for the exemption/redistribution.

This exemption will be in effect until August 31, 2025.

After Hours Exemption Form

 Extended Leave Notification Form

If patient care is not covered for a period of leave longer than 30 days, then capitation payments will be paused as of day 31 of leave until the physician resumes their practice. In these cases, physicians are to notify FPRP in writing in advance of the dates of the leave period by submitting this Extended Leave Form.

Please complete this form a minimum of 14 days before Day 1 of your leave. This will help ensure incorrect payments are not issued by MCP and that the payments will not need to be re-collected. 

If your leave is unexpected and you are unable to provide 14 days’ notice, please contact the Blended Capitation program specialist, Jason Clarke jclarke@nlma.nl.ca as soon as possible.

Extended Leave Notification Form

Please refer to the Family Practice Renewal Committee (FPRC) Policy on the Blended Capitation Group Model for additional information regarding leave policy.

Withdrawal Form

Participation in the Blended Capitation Model (BCM) is voluntary, and physicians may discontinue their enrolment by submitting a Blended Capitation Withdrawal Form.  Please complete this form and submit to FPRP at least 30 days in advance of your last day billing in the Blended Capitation Model.

Withdrawal Form

Please refer to the Family Practice Renewal Committee (FPRC) Policy on the Blended Capitation Group Model for additional information regarding withdrawal from the program, including the repayment of any owing amounts for pro-rated grants and stipends.