Lymphedema/Compression - Board of Certification/Accreditation

Lymphedema/Compression Form Application

* Indicates required entry

Facility Name

Doing Business As

Street Address

Suite Number

City

State

Zip Code

Country

Business Email

Secondary Email

Business Phone

Mobile Phone

Fax Number

CMS Provider # (PTAN)

National Provider Identifier (NPI)

Employer Identification # (EIN)

Is your facility currently accredited?

If yes, by which accrediting organization?

Posted Business Hours

Indicate AM/PM and if the facility closes for lunch. *Required entry for every day

Monday

Closed

Open Time

Closed Time

Closed For Lunch?

Closed

Lunch Start

Lunch End

Tuesday

Closed

Open Time

Closed Time

Closed For Lunch?

Closed

Lunch Start

Lunch End

Wednesday

Closed

Open Time

Closed Time

Closed For Lunch?

Closed

Lunch Start

Lunch End

Thursday

Closed

Open Time

Closed Time

Closed For Lunch?

Closed

Lunch Start

Lunch End

Friday

Closed

Open Time

Closed Time

Closed For Lunch?

Closed

Lunch Start

Lunch End

Saturday

Closed

Open Time

Closed Time

Closed For Lunch?

Closed

Lunch Start

Lunch End

Sunday

Closed

Open Time

Closed Time

Closed For Lunch?

Closed

Lunch Start

Lunch End

How Did You Hear About BOC?

How did you hear about BOC?

Did you use a Third Party Consultant?

If yes, Third Party Consultant Name*

Did you work with a BOC Business Development Representative?

Please select from the Dropdown:

Corporate Office/Owner(s) and Compliance Officer

Corporate Officer(s)

Owner(s)

Compliance Officer

Credentialed Personnel

Practitioner

Credential Type

Practitioner

Credential Type

Owner/Corporate Officer Signature

In signing this affidavit, I attest, upon personal knowledge, that all information reported in this application, including any and all accompanying documentation, is complete, accurate and true, to the best of my knowledge. I understand that falsification of information may result in a denial or revocation of accreditation. I agree to notify BOC in writing of all changes to ownership, corporate structure, location, or provision of services/equipment. In submitting this application, I agree to notify BOC that the facility is "site-survey ready" within one year of the date on the application. I understand that I am granting permission to BOC and its authorized representatives to inspect my facility during normal business hours and without prior notification.

Patient Files Attestation

I understand that our facility must have five (5) complete patient files, that meet CMS requirements, available at the time of the Site Survey. If the files are not available, a second in-person, on-site survey will be required once the facility confirms the files are complete and ready. Your facility will be required to pay an additional fee of $1,455 to cover the cost of the second on-site survey.

Type your name as your Electronic Signature:

Date (00/00/0000)

Facility Accreditation Fees

Fees

Lymphedema/Compression Site Survey and 3-Year Accreditation - $2,599

Total

Payment Information

Payment Type

Payment

Checkboxes

Check Enclosed

Check Number

Billing Address

City

State/Province

Zip/Postal

The issuer of the card identified on this form is authorized to pay the amount shown as Payment Amount upon proper presentation. I agree to pay such Payment Amount (together with any other charges due thereon) subject to and in accordance with the Agreement governing the use of such card. Make Check or Money Order payable to BOC. If your check is returned for any reason, you must submit a bank draft, money order, or credit card payment with an additional fee of $35.00 to cover the returned check processing fee. Applicants applying outside of the contiguous United States will be subject to an applicable surcharge for additional travel expenses. BOC does not offer refunds or accept post-dated checks.

An additional Site Survey fee of $1455.00 may be compulsory under specific circumstances. Under these circumstances the facilities will be notified prior to the survey taking place.

Notwithstanding anything to the contrary contained herein, to the maximum extent permitted by applicable law, except in the instance of willful misconduct or gross negligence of BOC (or any of its employees, agents, or contractors ("Related Parties")), the maximum aggregate liability of BOC arising out of or in connection with this Accreditation Application (including any inspection or audit of Applicant's facility) shall not exceed the aggregate amount paid or payable by Applicant to BOC for the Application fee and all services, including any inspection or audit, giving rise to such liability, as of the date of the events or circumstances giving rise to such liability.

Apply for Accreditation