EACR Program Provider Sign-up

Please review the Early Access Concussion Recovery Program Guide to ensure you meet the eligibility criteria before completing and submitting the application form to become an Approved Clinic within the EACR Program.

Following the submission, the applying clinic will be contacted by ICBC Recovery Programs and be required to provide a resume for each clinician referenced by the clinic in the application form.

Upon receipt of all requested information, ICBC will review the submission for a decision on whether the clinic meets the criteria to become an EACR Program Approved Clinic.

Company Profile

Principal Contact

Clinic information

Clinic #1

Clinic Director or Operations Manager

Name

Title

Phone (Required)

Email Address (Required)

Contact for Booking Appointments (to be shared with customers)

Name

Title

Phone (Required)

Email Address (Required)

Service Area (Required)

Please list the geographical areas in which you will provide EACR Program services.

Program Providers

List all clinicians that you wish to include in the EACR Program Provider list for your clinic. Ensure the providers listed meet the criteria identified in sections 3.3 and 3.4 of the Early Access Concussion Recovery program guide.

Provider #1

Provider Name (Required)

Provider Type (Required)

Vendor Number

Relevant Work Experience - Location List clinic names and dates

Relevant Work Experience Details Patient population, specialization

Relevant Courses/Certifications Including completion dates

+ Add more providers

– Remove a provider