Warning: count(): Parameter must be an array or an object that implements Countable in /home/aimis/public_html/wp-content/plugins/gravityforms/includes/fields/class-gf-field-list.php on line 464 GYN Center of Excellence Application 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 SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country CEO:CEO Phone #:ExtensionCMO:CMO Phone #:ExtensionDirector of Surgery:Director Of Surgery Phone #:ExtensionAdministrative Assistant:Admin Assistant Phone #:ExtensionContact 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):NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe 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):NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe 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?YesNoIf yes, how many?What system? Si Sie Xi How many robotic procedures per year?TypeGYNGeneral SurgeryUrologyOther Operative Room TypesDo you have dedicated MIS Rooms?YesNoIf yes, how many?Are your MIS rooms integrated?YesNoDo you have towers?YesNoName 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) TotalSSRAAll inclusive w/ or w/o adnexaTLH Procedure CPT Codes(Procedure codes can be located in current coding manuals)TotalSSRAAll inclusive w/ or w/o adnexaLAVH Procedure CPT Codes(Procedure codes can be located in current coding manuals)TotalSSRAAll inclusive w/ or w/o adnexaTVH Procedure CPT Codes(Procedure codes can be located in current coding manuals)TotalSSRAAll inclusive w/ or w/o adnexaTAH Procedure CPT Codes(Procedure codes can be located in current coding manuals)TotalSSRAYear 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 adnexa Re-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 adnexa Pelvic 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 adnexa Hematoma 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 adnexa Hemorrhage 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 adnexa Post 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 adnexa Puncture/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 adnexa Puncture/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 adnexa Puncture/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 adnexa Dehiscence 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 adnexa TOTAL 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 adnexa File UploadCV*Upload as a Word doc or PDFHospital BiographyAccepted file types: doc, docx, pdf.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 ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Date CAPTCHA
