Ancillary Facility/Supplier Business
In addition to a completed application you may be asked to submit the following, if it is applicable.
- Signed attestation statement
- Copy of Florida license(s)
- Copy of Florida registration
- Current certification of insurance (face sheet with expiration date and coverage amounts) to include errors and omissions for General and Professional liability
- Explanations for malpractice history and disciplinary actions
- Copy of accreditation documentation, if applicable (ASCs must be accredited)
- If performing MR, CT, PET, NC (includes cone bean CT)- The Joint Commission, IAC or ACR accreditation is required
- If performing mammography services, ACR Accreditation is Required
- Copy of applicable certification(s)
- Supervising physician statement, if applicable
- Copy of facility medical director’s curriculum vitae, medical license, DEA certificate – if applicable
- Copy of Medicare certification(s), if applicable
- Copy of Medicare participation letter, if applicable
- AHCA and/or CMS/Medicare site survey. If not obtained, a Florida Blue site visit is required.