Preceptor Payment Form RAN Red Deer

PRECEPTOR PAYMENT FORM – RAN RED DEER Date:

Dr. Address: Email / Fax (for preferred contact)

Dear Dr. , Our records show that the following Resident Physician [PGY1 or PGY2 Family Medicine Resident] undertook a/n [specify rotation type] with you in [specify discipline]:

Resident Time Away Total Length Total Payment **WebEval** Start Date End Date (Months, Weeks, Physician’s (vacation, Payment Rate Due (Rate x Completed (DD/MM/YY) (DD/MM/YY) Days) – LESS Time Name courses) Length) Away  $ $

To receive payment, you must complete the following information within 90 days of ROTATION END DATE: 1. Complete the trainee evaluation on **WebEval** (OR complete a paper copy supplied by the resident and/or RUC) AND 2. Complete and return this payment form within 90 days of the rotation end date (noted above) Please Note: For submissions past the 90 day deadline, PAYMENT WILL BE FORFEITED.

☐ An individual - Please provide Social Insurance Number: _ _ _--_ _ _--_ _ _ (9 digits) ☐ A Professional Corp or Sole Proprietor - Please provide Business Number: _ _ _ _ _--_ _ _ _ (9 digits) ☐ A clinic – Please provide Business Number: _ _ _ _ _--_ _ _ _ (9 digits) Name for payment: ______Mailing address: ______☐ Same address as above City: ______Province: ______Postal code: ______-______

______Date: ______Signature of Physician (Preceptor)

If you have questions, please contact the Rural Unit Coordinator at the address below: RETURN THIS COMPLETED FORM TO: Charlene Carver, Rural Unit Coordinator Rural Alberta North (RAN) – Red Deer Red Deer Regional Hospital |C10 3rd Floor, South Complex | 3942 50A Avenue | Red Deer, AB T4N 6R2 Tel: (403) 314-6085 | Fax: (403) 309-5889 | Email: [email protected]

The personal information requested on this form is collected for the purpose of administering and processing payments to preceptors, vendors, students, residents, contractors and staff involved with RPAP. If you have any questions about the collection, use, or disposal of the information requested, please contact: Executive Director, The Alberta Rural Physician Action Plan, 2801 Telus House, 10020–100 Street NW, Edmonton, AB T5J 0N3. Phone 780-423-9911 Toll Free 1-866-423-9911 Fax: 780-423-9917.

Form Number: F-9RD | Revised: 15 June 2015