MEDICARE SURGICAL

New Applicants

Below is a list of documentation that must be completed for the Medicare Ambulatory Surgery Center (ASC) Application. Please mail completed documentation to AAAASF at 7500 Grand Ave, Suite 200, Gurnee, IL 60031 or fax to 847-775-1985. You may also scan and email to reception@aaaasf.org.

  • Application Form with payment
  • Floor plan for facility
  • A copy of each physician’s State Medical License
  • A copy of each physician’s Board Certificate or letter of admissibility by the physician/surgeon certifying board (ABMS, AOABOS, ABOMS or ABPS as applicable)
  • A current copy of the hospital privileges approval letter, including the delineation of hospital privileges for each physician/surgeon (must state the department of surgical specialty and list the procedures that may be performed at the hospital)
  • Authorization to Release Information Form signed by each physician on staff
  • HIPAA Business Associate Agreement
  • Facility Identification Form
  • Staff Identification Form
  • Facility Director’s Attestation Form
  • Random Review Form (Six completed AAAASF Random Case Peer Review Forms and all Unanticipated Sequelae Forms from your facility’s semi-annual or initial review. New California, New York and Florida facilities with no cases, must complete Random Case Peer Review after completing their Provisional inspection.)
  • Unanticipated Sequela Form
  • A copy of the Certificate of Incorporation (NEW YORK APPLICANTS ONLY)
  • Proof that the 855B form has been processed by the Carrier
  • Equipment List

Once the documentation is received in the AAAASF office it will be reviewed within 10 business days and you will be contacted if additional paperwork is needed. Otherwise, once your file is complete you will be contacted regarding submitting your surgery schedule and hours of operation so that we may proceed with the unannounced Medicare Health survey and LSC survey.

AAAASF is required to conduct Validation Surveys on 5% of all Medicare Accredited Ambulatory Surgery Centers (ASCs) each year. As a Medicare provider, both the CMS State and AAAASF Central Office reserve the right to conduct an unannounced Validation Survey at any time during the certification process.

Please review the Standards and Checklist Manual carefully before submitting the completed documentation to AAAASF.

Download Documents

Self Survey – Before 2nd & 3rd Years Begin

Below is a list of documentation that must be completed for the Medicare Ambulatory Surgery Center (ASC) Self Survey. Please mail completed documentation to AAAASF at 7500 Grand Ave, Suite 200, Gurnee, IL 60031 or fax to 847-775-1985. You may also scan and email to reception@aaaasf.org.

  • Facility Identification Form
  • Staff Identification Form
  • Facility Director Attestation Form
  • Completed Standards Manual

Once received, please allow 10 business days for processing. If deficiencies are found, a report will be sent to the facility director allowing 10 calendar days for a Plan of Correction and 30 calendar days for proof of correction(s). Otherwise, once the documentation is processed, a new certificate will be mailed out to the facility at no cost.

AAAASF is required to conduct Validation Surveys on 5% of all Medicare Accredited Ambulatory Surgery Centers (ASCs) each year. As a Medicare provider, both the CMS State and AAAASF Central Office reserve the right to conduct an unannounced Validation Survey at any time during the certification process.

Please review the Standards and Checklist Manual carefully before submitting the completed documentation to AAAASF.

Download Documents

Re-Survey – Before End of 3 Year Cycle

Below is a list of documentation that must be completed for the Medicare Ambulatory Surgery Center (ASC) Re-Survey. Please mail completed documentation to AAAASF at 7500 Grand Ave, Suite 200, Gurnee, IL 60031 or fax to 847-775-1985. You may also scan and email to reception@aaaasf.org.

  • A copy of each physician’s State Medical License
  • A copy of each physician’s Board Certificate or letter of admissibility by the physicians certifying board (ABMS, AOABOS, ABOMS or ABPS)
  • A current copy of the hospital privileges approval letter, including the delineation of hospital privileges for each physician/surgeon (must state the department of surgical specialty and list the procedures that may be performed at the hospital)
  • Authorization to Release Information Form signed by each physician on staff
  • Facility Identification Form
  • Staff Identification Form
  • Facility Director’s Attestation Form
  • Equipment list
  • Copy of Floor Plan

Once all of the required documentation is received in the AAAASF office, it will be reviewed within 10 business days. You will be contacted if additional paperwork is needed. Otherwise, you will receive a request to submit your facility’s hours of operation and blackout dates so that a survey can be scheduled. An email confirmation will be sent to you once the survey has been arranged.

AAAASF is required to conduct Validation Surveys on 5% of all Medicare Accredited Ambulatory Surgery Centers (ASCs) each year. As a Medicare provider, both the CMS State and AAAASF Central Office reserve the right to conduct an unannounced Validation Survey at any time during the certification process.

Please review the Standards and Checklist Manual carefully before submitting the completed documentation to AAAASF.

Download Documents