Practice Specific Documents

The following providers need to send these documents with the Provider Enrollment Application and Core Agreement :

Ambulatory Surgery Centers

• Department of Health & Human Services-Medicare Certification for Ambulatory Surgery Centers (ASC)

Dentists

• Conscious Sedation/General Anesthesia Permit (If applicable)
• Oral Surgeons: Oral Maxillofacial Surgery Residency Certification required
• Access to Baby & Child Dentistry (ABCD) completion of training certification (If applicable)

Home Health Agency

• Home Health License from the Department of Health
• Copy of Medicare Certification

Hospice

• Copy of Medicare Certification
• Hospice License

Hospitals & Lab Facilities

• Clinical Laboratory Improvement Amendments (CLIA) Certificate
• Medicare Certification

Psychiatrists

• Graduation of Psychiatry Resident Program Certificate

Registered Nurse First Assist (RNFA) (Surgical Assists)

• RNFA Certification from Board of Preoperative Nursing
• CNOR Certification from Board of Preoperative Nursing
• Written documentation of allied health personnel privileges in hospital(s)
• Letters of recommendation to assure quality of care as RNFA