Mastectomy Form Application
* Indicates required entry
Posted Business Hours
Indicate AM/PM and if the facility closes for lunch. *Required entry for every day
How Did You Hear About BOC?
How did you hear about BOC?
Corporate Office/Owner(s) and Compliance Officer
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 understand that I am granting permission to BOC and its authorized representatives to inspect my facility during normal business hours and without prior notification.
Facility Accreditation Fees
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 made aware of this 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.