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FEE CODE PROGRAM REGISTRATION FORM

PHYSICIAN INFORMATION

Surname
Dodge
Given Name and Initial
Samantha J
College of Physicians and Surgeons License No.
F10389
MCP Provider No.
168840

Program Eligibility

Participation in the Program is subject to eligibility requirements.

Within 90 days from date of physician registration, physician eligibility will be validated through both physician-provided and MCP data. On an ongoing basis, reviews, random or otherwise, will be conducted to verify continuing physician compliance with eligibility criteria.

Wherever possible, FPRP will support efforts to achieve compliance. However, where, at any time and in the sole discretion of the FPRP, it is determined that a physician is not compliant with the eligibility requirements of the Program and there is no reasonable prospect of the physician achieving such compliance, the FPRP may deny or revoke, as the case may be, a physician’s participation in the Program.

Please check the box next to the statements that apply to you.

To participate in the Program, you (the Fee-For-Service Family Physician):

  1. Have a valid practitioner number for practice in Newfoundland and Labrador.
  2. As designated primary care physician, have indicated and recorded your commitment to established longitudinal relationships with your patients whereby you commit to the overall responsibility of the coordination of patient care needs. If you do not provide a particular service needed at any given time (e.g. Obstetrics), you will coordinate the referral to a colleague who is able to provide that service in a shared care arrangement with the patient’s family physician.
  3. Have either adopted an Electronic Medical Record (EMR) in practice or have signed an EMR Physician Participation Agreement.
  4. Note: Checking the box in #4 below means, you currently perform the service at the stated level OR you can demonstrate a clear and consistent pattern, which, if continued, would meet the requirement(s) of the stated service level(s).

    Example: You are new to practice and although you regularly provide after hours care and regularly conduct medical care visits to your own patients in their personal residences, you do not meet the annual requirement as stated in the criteria as you have only been in practice for 3 months. Are you eligible for registration?

    Yes, if you can demonstrate a clear and consistent pattern, which, if continued, would meet the requirement of the stated service level, you are eligible to participate in the Program.

    Please check the statements that apply to you.
    1. I provide after-hours care/extended hours in my practice (i.e. before 9:00 am or after 5:00 pm on weekdays, or a weekend clinic) for at least 90 hours annually.
    2. I participate in a structured after-hours (i.e. before 9:00 am or after 5:00 pm on weekdays, or a weekend clinic) rotation with a group of family physicians, whereby each physician sees the patients of any physician within the group, for at least 90 hours annually OR I am part of an RHA-sponsored after-hours primary care clinic with a prescribed limit on the number of hours I can work.
    3. I provide hospital services (e.g. care to own patients when admitted to an acute care facility, participation in a structured rotation to provide care for admitted patients, Emergency Department coverage, Chemotherapy Management, surgical assists, etc.) within RHA facilities.
    4. I regularly perform medical care visits to my own patients residing in long-term care facilities or personal care homes.
    5. I regularly conduct medical care visits to my own patients in the patient’s personal residence, completing a minimum of 50 visits annually.
    6. I provide access to a minimum of 5 same-day appointments in my practice per full office day or equivalent thereof.
    7. I employ and collaborate with an LPN, RN, NP, or other primary health care professional in my practice in a multi-disciplinary or interdisciplinary team environment OR I regularly collaborate with a RHA-employed LPN, RN, NP, or other primary health care professional in a multi-disciplinary or interdisciplinary team environment.
    8. I am a member of a group family practice, defined as two or more family physicians participating in a shared practice, whereby each physician sees the patients of any physician, when their designated physician is unavailable.
    9. I regularly provide labour and delivery services (i.e. clear and consistent pattern, considering birth rates in the practice area).
    10. I participate in physician leadership initiatives that encourage and facilitate primary care renewal and system change. Examples may be FPRP or RHA leadership roles (e.g. participating in Family Practice Network leadership group or Community Medical Advisory Committee) OR I perform a preceptor role with the MUN Faculty of Medicine’s Undergraduate or Postgraduate programs OR I perform a Clinical Chief role within my RHA).
    11. I manage office-based emergencies or perform minor procedures that would otherwise necessitate emergency room visits or specialist referrals. These include: abscess draining; biopsies; casting; electrocardiograms; excisions; IUD insertions; removal of corneal foreign bodies; spirometry; suturing of lacerations; and vasectomies.

Note: In relation to #3 above, if, at the time the EMR process is to be initiated, you decide to withdraw, you are required to meet six (6) of the requirements in #4 above. Please contact FPRP to complete a revised registration form.

Note: If you currently do not meet Fee Code Program eligibility requirements and would like to discuss this further, please contact a member of the Family Practice Renewal team.

Terms and Conditions of Registration

Your registration in the Fee Code Program (“Program”) is subject to the terms and conditions of the agreement below (“Agreement”). To accept the terms and conditions, to be bound by them and to be eligible for registration in the Program, you must read and accept this Agreement. To accept, click on the “I agree” box below.

  1. Entire Agreement - The above Fee Code Program Registration Form (“Form”) is incorporated as part of this Agreement. This Agreement represents the entire understanding between the parties with respect to its subject matter.
  2. Validation of Eligibility Requirements - I understand that FPRP requires information from MCP about the health care I provide (“Information”) for validation of eligibility requirements stated in the Form.
  3. Failure to Meet Eligibility Requirements - I acknowledge that failure to meet or maintain eligibility requirements at any time will result in denial, suspension or termination of registration in the Program.
  4. MCP – I understand that MCP is subject to the Medical Care and Hospital Insurance Act, Access to Information and Protection of Privacy Act (ATIPPA) and the Personal Health Information Protection Act (“Legislation”).
  5. NLMA Privacy Policy – I understand that FPRP abides by the NLMA Privacy Policy, and as such, any information collected will be limited to that which is reasonably necessary for the purpose stated. I understand FPRP will hold personal information in confidence and will not use, disclose or retain information for purposes other than those stated, except with express physician consent.
  6. Disclosure to Third Parties - I understand that FPRP may disclose personal information (i.e. criteria- related activities in requirement 3, Program Eligibility) to third parties (i.e. external firm contracted to conduct eligibility compliance) that are not FPRP-affiliated if those third parties have contracted with FPRP to assist in providing products and services. In such circumstances, FPRP will take reasonable contractual measures to ensure that personal information is protected by those third parties at a level comparable to the requirements of ATIPPA.
  7. Consent Required - I understand that the disclosure to and the use of the Information by FPRP is necessary to participate in the Program. Should I choose not to provide consent for disclosure to FPRP of the Information I will not be eligible to participate in the Program.
  8. Consent Given - I hereby consent to MCP providing FPRP with the Information in accordance with the Legislation.
  9. Consent Revoked - I acknowledge my participation in the Program is voluntary and I may revoke my consent, and my participation, at any time, by completing the 'Revocation of Registration and Consent' Form and submitting it to FPRP.
  10. Changes in Program - I understand the design of the Program may be altered over time, including the conditions and fees associated with each code. I understand that in such circumstances, physicians will be notified and have the opportunity to withdraw their consent and participation by completing the ‘Revocation of Registration and Consent’ portion of the Form.
  11. Information True and Accurate - I confirm that I have read and understand the terms and conditions above and that the information that I have provided in the Form is true and accurate.

I Agree. I acknowledge that by clicking on this box I have entered into a binding agreement with the FPRP on the terms and conditions stated above.

Date: Thursday, December 2nd 2021