Get Application For A Site Visit (80k Pdf) - American College Of Surgeons

This guide aims to assist users in completing the Application For A Site Visit for the American College of Surgeons. By following these detailed instructions, you can ensure a smooth application process.

Follow the steps to complete your application effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your editor of choice.
2. Enter the facility name and mailing address. Ensure that it does not include a P.O. Box, as this information is required for verification purposes.
3. Provide contact details including phone number, fax number, and email address of the facility for communication purposes.
4. If applicable, fill out the pediatric facility name and mailing address in the designated fields.
5. Indicate any previous names of the facility and provide the facility's website, Federal Employer Identification Number (FEIN), and National Provider Identifier Number (NPI).
6. Select your preferred timeframe for the visit, ensuring to provide both the earliest and latest available dates in a two-month span.
7. Choose the type of visit you are applying for. Options include verification, reverification, consultation, and focused visit, along with corresponding fees.
8. Complete the contact information for your state or county's Department of Health or EMS agency, including name, title, office phone, and email.
9. Enter the contact details for the trauma medical director, including name, phone number, cell phone or pager, and email address.
10. If seeking a combined visit, fill out the pediatric trauma medical director's contact information.
11. Provide the trauma program manager or coordinator's contact details and any additional pediatric program manager or coordinator information, if applicable.
12. Obtain the signature of an authorized personnel, confirming the validity of the application and readiness to proceed with the accreditation process.
13. Check the box to agree or disagree with the statement, and ensure the authorized person's name, title, phone number, and email are filled in.
14. If additional reviewers are needed, request them and provide their names and specialties as instructed.
15. Once all sections are filled out accurately, save your changes and consider downloading, printing, or sharing the completed form to submit.

Complete your Application for a Site Visit online today and ensure your facility is prepared for accreditation.