Office-based surgery / procedures physician registration form

NOTE: A copy of the form will be emailed to you.

* indicates a required field

Name and license number



Practice address






List specialty(ies) - Choose a specialty or Select None (DO NOT TYPE CHOOSE FROM LIST)






List all Specialty Board Certifications (from specialty boards approved by the American Board of Medical Specialties or the American Osteopathic Association):

Allergy and Immunology Anesthesiology
Colon and Rectal Surgery Dermatology
Emergency Medicine Family Medicine
Family Physicians Internal Medicine
Medical Genetics Neurological Surgery
Neurology & Psychiatry Nuclear Medicine
Obstetrics and Gynecology Ophthalmology
Ophthalmology & Otolaryngology Orthopaedic Surgery
Otolaryngology Pathology
Pediatrics Physical Medicine and Rehabilitation
Plastic Surgery Preventive Medicine
Psychiatry and Neurology Proctology
Radiology Surgery
Thoracic Surgery Urology
Or
No Board Certifications

1. Do you perform any procedures in the office-based setting in which one or more of the following levels of anesthesia are utilized?


No Yes* Not Answered



 


No Yes* Not Answered


 


No Yes* Not Answered


 



No Yes Not Answered



No Yes* Not Answered


No Yes NA



No Yes* Not Answered


No Yes NA



No Yes* Not Answered



 



No Yes Not Answered

Accreditation Association for Ambulatory Health Care (AAAHC)
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

No Yes NA


I (the physician) swear (affirm) that the information set forth on this Office-Based Surgery / Procedures Registration Form is true and correct to the best of my knowledge, information and belief. I also understand that the Board of Medical Examiners may conduct an on-site inspection at any time.


 

This form uses Huggins' Email Form Script

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