Ambulatory Surgery Centers - Hanover InsuranceServices % # of Procedures Annual Projection Neuro...
Transcript of Ambulatory Surgery Centers - Hanover InsuranceServices % # of Procedures Annual Projection Neuro...
This application must be completed in conjunction with the Allied Healthcare Facility Common Application
INSTRUCTIONS
1. Please read the instructions carefully. Complete and submit all requested information and/or required attachments. This application and all materials submitted shall be held in confidence.
2. All application questions must be fully answered. If a question does not apply, please write “N/A”.
3. If you need more space, continue on a separate sheet of your letterhead and indicate the question number.
1. Name of Applicant: _______________________________________________________________________________________
2. Services
A. What surgical specialties/procedures are provided at the facility(s)? If services cross specialties, do not duplicate numbers. Assign to one specialty.Please provide information by state.
Selected State: _____________
Services % # of Procedures Annual Projection
Abortions
Bariatric (see breakout below)
– Laparoscopic Gastric Bypass, including Rouex-en-Y Gastric Bypass
– Adjustable Gastric Band, including LAP-BAND®
– General Surgery approach Gastric Bypass
– Distal Gastric Bypass
– Billiopancreatic Diversion
– Gastroplasty
– Gastric Sleeve
– Other (please describe)
Birthing Centers
Cardiac
– Catheterization/Angioplasty
– Cardiac Pacing
– Implantable Cardioverter-defibrillator, Lead, Pacemaker
Dental oral and Maxillofacial
Endoscopy/Colonoscopy
ENT/Otorhinolaryngology
Gastrointestinal/GI
General Surgery
Gynecological Surgery
Imaging - venography, fluoroscopy, & ultrasonic needle guidance
In vitro fertilization
Lithotripsy
S U P P L E M E N T A L A P P L I C A T I O N
Ambulatory Surgery Centers
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Services % # of Procedures Annual Projection
Neuro (including Gamma knife)
Ophthalmology
– LASIK
– Non-LASIK
Orthopedic
Pain management
– Anthroplasty including-facetectomy, laminectomy, foraminotomy
– Discectomy & Micro-discectomy
– Vertebral column fixation/spinal fusion (non-instrumented)
– Sacroplasty
– Other (please describe)
Plastic Surgery Cosmetic and Reconstructive Surgery
– Cosmetic
– Reconstructive
Podiatric
Radiation oncology/therapy/chemotherapy
Thoracic
Urologic
Vascular
Other (Please Describe)
Total
B. Overnight Recovery Beds Yes No
C. If the stays are longer than 24 hours, how many beds? ______
D. Patient Selection
1. Based on the ASA Physical Status Classification System, what percentage of patients are accepted annually?
P1 A normal healthy patient
P2 A patient with mild systemic disease
P3 A patient with severe systemic disease
P4 A patient with severe systemic disease that is a constant threat to life
P5 A moribund patient who is not expected to survive without the operation
P6 A declared brain-dead patient whose organs are being removed for donor purposes
2. Do you treat professional athletes or celebrities? Yes No
3. ACCREDITATIONS AND LICENSURE (Provide dates of certification. If not applicable select “N/A”)
A. Licensure/Accreditations/Special Awards/Center of Excellence
Date of Expiration N/A
State Licensure
Medicare Certification
AAAASF – Amer. Assoc. for Accreditation of Ambulatory Surgery Facilities
AAAHC – Accreditation Association for Ambulatory Health Care, Inc.
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Date of Expiration N/A
HFAP – American Osteopathic. Association, Healthcare Facilities
Accreditation Program
Institute for Medical Quality (IMQ)
TJC The Joint Commission
Other: (Please Describe)
B. Were any deficiencies cited in the most recent surveys? Yes No
C. If this is a new operation, will accreditation be sought within the next 12 months? N/A Yes No
4. EMPLOYEES/INDEPENDENT CONTRACTORS INFORMATION
A. Licensed/Non-Licensed
Licensed Number Full-Time
Number Part-Time
Annual Payroll Number of 1099’s
Advanced Practice Nurses/ Nurse Practitioners/ Midwives
Certified Medical Assistants
Certified Nurse Assistants
Interns
Nurses (RN, LPN, LVN)
Pharmacists
Physician Assistants/ Surgeon Assistants
Residents
Students
Technicians
Technologists
Therapy Aides/ Assistants
Other: (Please Describe)
B. Does applicant want coverage to include independent contractors? Yes No
C. Does applicant obtain certificates of insurance from independent contractors? Yes No
COMMENTS
Please provide any additional information or requests not reflected in the application
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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126-0116 (7/14)
hanover.com
The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653
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AUTHORIZATION
I have answered the questions in the Application to the best of my ability and declare that, to the best of my knowledge, the statements set for the herein are true and correct. My signing of the Application does not bind the Insurance Company to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a policy be issued.
FRAUD NOTICE–Where Applicable Under The Law of Your State
Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and may be subject to civil fines and criminal Penalties.
For New York Residents only: and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.
For Pennsylvania Residents only: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.
For Tennessee Residents only: Penalties include imprisonment, fines and denial of insurance benefits.
SIGNATURE IN FULL: __________________________________________________ DATE: ________________________________
PRINT NAME: ________________________________________________________
ALL QUESTIONS MUST BE ANSWERED AND THE APPLICATION MUST BE SIGNED AND DATED
Agency Name and Address: _____________________________________________________________________________________
Person Submitting Application: __________________________________________________________________________________
Telephone Number: _____________________________ Email: _______________________________________________________