General Surgery Physician Membership Application

13506 Summerport Village Pkwy.
Box 253
Windermere, FL 34786
Phone 407-376-3110
Fax 407-850-0293
www.AIMIS.org
GYNECOLOGY SURGERY "CENTER OF EXCELLENCE" HOSPITAL APPLICATION (GCOE)
Contact Information
Hospital / Institute Name:*
Address: Suite City State / Province / Region ZIP / Postal Code Country
CEO:
CEO Phone #:
Extension
CMO:
CMO Phone #:
Extension
Director of Surgery:
Director Of Surgery Phone #:
Extension
Administrative Assistant:
Admin Assistant Phone #:
Extension
Contact Representative (person completing application):
Phone
Email
Fax
Other:
Please describe:

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AIMIS Survey Questions for Initial Application and Survey

Practice Profile
I consider myself: (check all that apply)
- General Surgeon
- Colon Rectal
- Bariatric
Is your practice a: (check all that apply)
- Solo Practice
- Group Single-Specialty Practice
- Group Multi-Specialty Practice
- Hospital Employed Practice
- Academic Center

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General Procedures
Hospital-Based Surgeries completed in 2017
Cholecystectomy Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
Total
SS
RA
Appendectomy Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
Total
SS
RA
Small Bowel Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
Total
SS
RA
Colon Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
Total
SS
RA
Nissen Fundoplication Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
Total
SS
RA
Ventral Hernia Repair Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
Total
SS
RA
Inguinal Hernia Repair Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
Total
SS
RA
Stomach Procedures Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
Total
SS
RA
AIMIS GENERAL SURGERY- MEMBERSHIP

Accredited Physician – Surgeons at this membership level have advanced their surgical skills and have become accredited by AIMIS. As an accredited member, the Doctor provides procedural and outcome data and is recognized by the health plans as a selected surgeon with financial benefits. A surgeon can designate any or all surgeries to be recognized as accredited. The following criteria:

O.R.-Based Surgeries: Performs 60% Of MIS
Cases Done Per Year
Cholecystectomy
Nissen Fundoplication
Ventral Hernia Repair
Inguinal Hernia Repair
Appendectomy
Small Bowel Resection
Colon
Stomach
Name*
First Last
Date*
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CV*
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Hospital Biography
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General Surgery Physician Membership Application

General Surgery Physician Membership Application

Step 1 of 4

GYNECOLOGY SURGERY "CENTER OF EXCELLENCE" HOSPITAL APPLICATION (GCOE)

Contact Information

Academic Affiliation:

1. Other Hospital Location(s):

2. Other Hospital Location(s):

AIMIS Survey Questions for Initial Application and Survey

General Procedures

Hospital-Based Surgeries completed in 2017

AIMIS GENERAL SURGERY- MEMBERSHIP

File Upload