E. Services provided under this license:
Coded as follows: 1. Provided directly by employee, 2. Provided by a contract service, 3. Both 1 and 2.
Ancillary Services:
Laboratory
Radiology
EKG
Pharmacy
Surgical Services:
Cardiovascular
Foot
General
Neurological
Obstetrics/Gynecology
Ophthalmology
Oral
Orthopedic
Otolaryngology
Plastic
Thoracic
Urology
Gastroenterology
Other
F. Number of Operating Rooms (as classified in the AIA, 2001 guidelines):
Class A
Class B
Class C
Endoscopy
G. Off-site centers:
Are there off-site facilities under this license?
_____ Yes
_______No
If yes please complete the following information:
Name
Address/City./State/Zip
Telephone Number
H. Accreditation:
Does this center have accreditation that is “deemed” to meet CMS Conditions of Coverage?
_____Yes
_____No
If accredited, please complete the following:
Name
Effective Date of Accreditation
Expiration Date of Accreditation
I. Type of Entity:
For Profit
Non-Profit
Government
•
•
•
Individual
Church Related
State
•
•
•
Partnership
Individual
County
•
•
•
Corporation
Partnership
City
•
•
•
Limited Liability Company
Corporation
City/County
•
•
•
Sole Proprietorship
Limited Liability Company
Hospital District
•
•
•
Other (specify) _____________________________
Other (specify) _____________________
Federal
•
_____________________________________________
_____________________________________
Other (specify) ________________
_____________________________________________
_____________________________________
________________________________
_____________________________________________
_____________________________________
________________________________
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