__________________________________________________________________________________ Medicare ASC • Medicare RHC • Medicare RA/OPT• ASF Surgical • ASF Oral Maxillofacial • ASF Procedural ACCREDITATION OFFICE: 5101 Washington Street, Suite 2F • P.O. Box 9500, Gurnee, Illinois 60031 • Toll Free 1-888-545-5222 Phone 847-775-1970 • Fax 847-775-1985 • E-mail: reception@aaaasf.org • Web Site: www.aaaasf.org REGISTRATION FORM AAAASF Surveyor Training Workshop ASPS The Meeting 2014 Friday, October 10, 2014 Chicago, Illinois Regular Course 8 a.m. to Noon and Medicare Course 1 to 5 p.m. The registration fee for this workshop is waived for two AAAASF accredited facility physicians and nurses attending the workshop for the purpose of becoming an AAAASF certified surveyor. The AAAASF office must have a completed registration form for each individual attending the workshop. Registration confirmation will be sent to you when your registration form is processed. A registration fee will be charged for non-AAAASF participants. The registration fee for Regular and Medicare courses is $350 each. On-site registration will be available for $400 for each course only if space is available. ASPS is offering approved CME credits for these courses and should be contacted directly for additional information about the number and type of credit hours per course, as well as the subsequent individual transcripts of credits earned per course. AAAASF does not have access to this information. □ I am attending to become a surveyor Name: _________________________________________ Must provide copy of MD or RN License with registration form_______________ Title (circle one): M.D. R.N. Retired (circle one): Y / N Facility Name: ___________________________________________________________Facility ID #:__________ Address: ____________________________________________________________________________________ Phone/ Work: _______________________Home:________________________Cell:________________________ Fax: ____________________________ E-Mail: ____________________________________________________ Preferred method of contact (circle one) : Home Phone Work Phone Select the course you wish to attend: ⁮ REGULAR (a.m. course) Cell Email ⁮ MEDICARE (p.m. course) ⁮ BOTH If a registration fee is applicable, please complete the following information: Check # _______ Please make all checks payable to AAAASF Credit Card: (circle one) Visa MasterCard American Express Account #:_____________________________________________ Expiration date: ________________________ Cardholder’s name: __________________________________Signature: _________________________________ Mail registration form and payment to: AAAASF Office, P.O. Box 9500, Gurnee, IL 60031 OR fax to: 847-775-1985 Attention Linda Deubel A completed Registration Form MUST be submitted for each workshop participant. Please make additional copies if needed. Policy for Surveyor Qualification To ensure that a surveyor is adequately qualified to perform AAAASF facility surveys, the surveyor must meet the following criteria: 1. Be a qualified physician or registered nurse able to provide documentation of current license. 2. Submit a current Curriculum Vitae that documents experience to qualify as a certified surveyor. 3. Sign and adhere to the initial AAAASF Surveyor Agreement, including Surveyor Attestation, Conflict of Interest, Code of Conduct, Surveyor Guidelines, and agreement to participate in annual surveyor appraisal and review process conducted by AAAASF Quality Assurance Program and submit the same to AAAASF office. 4 . Attend an AAAASF Medicare surveyor in service training course complete and pass the Surveyor training examination administered at the conclusion of each training course, a certificate of completion will be kept on file in the AAAASF Office.