Step 1 of 4 25% 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 InformationHospital / Institute Name:* Address: Suite City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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): PhoneEmail FaxOther: Please describe: Academic Affiliation:Do you have MIS Fellowship training program? If so, please list:SpecialtyNumber of Fellows Click the plus sign to add another row.Unique Services Offered at your Institution(s): Please check all that apply Urogynecology GYN Oncology Reproductive, Endoocrine, Infertility Medicine Endometriosis Pelvic Pain Is your hospital... Community Based (Corporate Chain) Community Base (Locally Owned) Private Academic County City University / State Owned Academic For Profit Nonprofit Other Choose all that apply.1. Other Hospital Location(s):Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website CEO: First and Last Name Phone # and extension COO: First and Last Name Phone # and extension Physician Relation Representative: First and Last Name Phone # and extension 2. Other Hospital Location(s):Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website CEO: First and Last Name Phone # and extension COO: First and Last Name Phone # and extension Physician Relation Representative: First and Last Name Phone # and extension Do you offer Robotics? Yes No If yes, how many?What system? Si Sie Xi How many robotic procedures per year? TypeGYNGeneral SurgeryUrologyOtherOperative Room TypesDo you have dedicated MIS Rooms? Yes No If yes, how many?Are your MIS rooms integrated? Yes No Do you have towers? Yes No Name of GYN Coordinator First Last Number of Physicians affiliated with your OB/GYN Department: Name of GYN Physician Director of the MIS GCOE First Last Designated AIMIS Surgeons in Your Program:NameSpecialty Click plus sign to add more rows. a. Hospital-Based Surgeries Please provide the total number of surgical procedures for each CPT Code category for the 2016 year. All inclusive w/ or w/o adnexaLSH Procedure CPT Codes (Procedure codes can be located in current coding manuals) Total SS RA All inclusive w/ or w/o adnexaTLH Procedure CPT Codes (Procedure codes can be located in current coding manuals)Total SS RA All inclusive w/ or w/o adnexaLAVH Procedure CPT Codes (Procedure codes can be located in current coding manuals)Total SS RA All inclusive w/ or w/o adnexaTVH Procedure CPT Codes (Procedure codes can be located in current coding manuals)Total SS RA All inclusive w/ or w/o adnexaTAH Procedure CPT Codes (Procedure codes can be located in current coding manuals)Total SS RA Year of 2017 Instructions: Please complete the above data collection for AIMIS review. We would like to collect the following: Total number of procedures, conversions to open, readmissions (note this will be first admits for same day surgery) and complications. Converted to Open: ICD9 Code V64.41LSH all inclusive w/ or /wo adnexaTLH all inclusive w/ or /wo adnexaLAVH all inclusive w/ or /wo adnexaTVH all inclusive w/ or /wo adnexaTAH all inclusive w/ or /wo adnexaRe-AdmissionLSH all inclusive w/ or /wo adnexaTLH all inclusive w/ or /wo adnexaLAVH all inclusive w/ or /wo adnexaTVH all inclusive w/ or /wo adnexaTAH all inclusive w/ or /wo adnexaPelvic Abscess N73.9LSH all inclusive w/ or /wo adnexaTLH all inclusive w/ or /wo adnexaLAVH all inclusive w/ or /wo adnexaTVH all inclusive w/ or /wo adnexaTAH all inclusive w/ or /wo adnexaHematoma l 97.62LSH all inclusive w/ or /wo adnexaTLH all inclusive w/ or /wo adnexaLAVH all inclusive w/ or /wo adnexaTVH all inclusive w/ or /wo adnexaTAH all inclusive w/ or /wo adnexaHemorrhage 998.11LSH all inclusive w/ or /wo adnexaTLH all inclusive w/ or /wo adnexaLAVH all inclusive w/ or /wo adnexaTVH all inclusive w/ or /wo adnexaTAH all inclusive w/ or /wo adnexaPost Op Infection/Cystitis T81.4XXALSH all inclusive w/ or /wo adnexaTLH all inclusive w/ or /wo adnexaLAVH all inclusive w/ or /wo adnexaTVH all inclusive w/ or /wo adnexaTAH all inclusive w/ or /wo adnexaPuncture/Laceration Ureter N99.71/N99.72LSH all inclusive w/ or /wo adnexaTLH all inclusive w/ or /wo adnexaLAVH all inclusive w/ or /wo adnexaTVH all inclusive w/ or /wo adnexaTAH all inclusive w/ or /wo adnexaPuncture/Laceration Bladder N99.71/N99.72LSH all inclusive w/ or /wo adnexaTLH all inclusive w/ or /wo adnexaLAVH all inclusive w/ or /wo adnexaTVH all inclusive w/ or /wo adnexaTAH all inclusive w/ or /wo adnexaPuncture/Laceration Bowel K91.71/K91.72LSH all inclusive w/ or /wo adnexaTLH all inclusive w/ or /wo adnexaLAVH all inclusive w/ or /wo adnexaTVH all inclusive w/ or /wo adnexaTAH all inclusive w/ or /wo adnexaDehiscence T81.31Xa/ T81.32XALSH all inclusive w/ or /wo adnexaTLH all inclusive w/ or /wo adnexaLAVH all inclusive w/ or /wo adnexaTVH all inclusive w/ or /wo adnexaTAH all inclusive w/ or /wo adnexaTOTAL COMPLICATIONS:LSH all inclusive w/ or /wo adnexaTLH all inclusive w/ or /wo adnexaLAVH all inclusive w/ or /wo adnexaTVH all inclusive w/ or /wo adnexaTAH all inclusive w/ or /wo adnexaFile UploadCV*Max. file size: 256 MB.Upload as a Word doc or PDFHospital BiographyAccepted file types: doc, docx, pdf, Max. file size: 8 MB.Upload as a Word doc or PDFGYN PHYSICIAN MEMBERSHIP: 450 USD **This is a secure website. You can safely fill your credit card payment details. By filling this information you give AIMIS permission to charge your credit card in the amount of 450 USD. You will receive a receipt for this transaction as soon as your card is billed.**If you are outside the U.S., please use any currency converter such as this one to convert to your currency.Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Date MM slash DD slash YYYY CAPTCHA
