Get Asc Application Initial - Alaska Department Of Health And Social ...

Filling out the ASC Application Initial is an essential process for establishing an ambulatory surgical center in Alaska. This guide provides clear and detailed instructions to assist you in completing the application online.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to access the ASC Application Initial document, ensuring that you save this form to your hard drive before you begin filling it out.
2. Begin by entering the exact legal name of your ambulatory surgical center in the designated field, followed by the ‘doing business as’ name, if applicable. Complete the address information including street number, city, state, and zip code.
3. Next, provide the main phone number for public use, as well as the administrative phone number and fax number for the Health Facilities Licensing and Certification (HFL&C) use.
4. Fill out the section regarding ownership and administration. Indicate the type of control by selecting the appropriate checkbox for governmental, not-for-profit corporation, or proprietary ownership.
5. If the ownership is individual or partnership, list all owners' names and addresses, along with any additional names under which owners do business.
6. If applicable, include details of corporate ownership and list the names and addresses of corporate officers, as well as shareholders holding more than five percent of shares.
7. Document the personnel section where you need to provide the administrator's, medical director's, and supervising nurse's details, including names, addresses, telephone numbers, and any relevant license or certification numbers.
8. List the medical staff and their specialties along with their names and license numbers, ensuring to include all individuals granted privileges to perform procedures.
9. Complete the facilities, services, and procedures section by preparing and including required exhibits such as schematic architectural plans and documentation of compliance with safety codes.
10. Confirm your facility's accreditation status, and document your malpractice insurance details if applicable.
11. Ensure compliance with criminal background checks as per regulations, confirming if a system is in place for this purpose.
12. Finally, review your entries for accuracy and completeness. Sign the application on behalf of the applicant, including the necessary details of the administrator or designee.
13. Once all sections are complete, save your changes. You may choose to download, print, or share the form as needed.

Complete your ASC application online today to facilitate the licensing process!