Apply cote Form Review

ACCREDITATION APPLICATION

1. Basic Information:

^*Type of Applicant Center:

In Patient Hospital/Medical Center

Outpatient Ambulatory Surgery Practice

Medical/Multidisciplinary Practice

Behavioral Health/Mental Health/Nutrition Health Practice

^*Name of center

^*Total number of Employees:

^*Country

^*Address

^*City

^*State/Region

^*2. Business Model

Business Model: ( You can check more than one )

Not-for Profit

Corporation

Limited Liability Corporation

Sole Proprietor /Private Practice

Government Center

note : atleast 1 need to be selected.

3. Identifying Information

Leadership

Name, title, and contact information of organization’s Leadership.

^*Name

^*Title

^*Country

^*Address

^*City

^*State/Region

^*Phone

Web address

COTE Compliance Coordinator

^*Name

^*Title

^*Country

^*Address

^*City

^*State/Region

^*Phone

^*Email

4. Executive Summary and Background: This Executive summary is intended to provide the COTE application survey team with an overview of the services/treatment modalities provided for your patient population. You can include center’s mission/philosophy, and why the applicant is uniquely qualified to receive the designation of Center of Therapeutic Excellence. This summary could also identify health professionals that are most instrumental in facilitating the mission and goals of your center ( 750 words maximum ).

^*5. Attestations

Insert [ ✓ ] in each of the following statements to attest that the applicant is in compliance :

The applicant is a legal entity and is properly licensed, certified or accredited to operate in the jurisdiction in which it is located.

The applicant or any of the applicant’s employees, agents, independent contractors or sub-contractors have not been convicted of, pled guilty to or pled nolo contendere to any health care related offence.

The applicant has no current or pending disciplinary actions.

applicant is in good standing with all regulatory agencies.

The applicant has read, understands, and accepts the mandatory requirements, responsibilities, and terms and conditions associated with these COTE accreditation standards.

The applicant does not discriminate in its employment practices with regard to race, color, religion, age, sex, marital status, sexual orientation, political affiliation, national origin, or handicap.

The applicant follows all required safety protocols, has safety policies in place, and has established emergency protocols for health and safety related incidents.

The applicant has in place all furniture, fixtures and medical and surgical equipment and appropriate infrastructure needed to accommodate and facilitate the care of obese individuals.

If your center does not fully complywith any of the above attestations please provide an explanation (max 200 words)

6. Oversight

Attach list of current Board of Directors/Trustee or advisory board Member(if applicable)

	Name	Board of Director	Trustees	Advisory Board

(+) add more

7. Licenses / Accreditations /Certifications:

Name of Accreditation	Start Date	End Date	Current

(+) add more accreditation

Licenses:

Name of License	Start Date	End Date	Current

(+) add more Licenses

Certificate:

Name of Certificate	Start Date	End Date	Current

(+) add more Certificate

8. Administration & Data Management

The applicant supports Continuing Education Programs to keep health care providers current with emerging science related to obesity/diabesity management.

The applicant has policies and procedures in place to protect sensitive patient health care information from being disclosed without the patient consent or knowledge.

The applicant has process in place for dispute resolution for both patient and staff.

The applicant agrees to participate in collaborative sharing of anonymous data to aid in applicable research

applicant has a referral plan in place for allied supplementary support services.

If applicant does not currently comply with the above policies, please explain below

^*9. Education

The number of Health Care Professionals who are AABC Board Certified in Bariatric Science – Please include names and AABC Certification no.

4 or more

None

Name of HCP	AABC certification no

(+) add more

ACCREDITATION APPLICATION

1. Basic Information:

^*2. Business Model

3. Identifying Information

Leadership

COTE Compliance Coordinator

^*5. Attestations

6. Oversight

7. Licenses / Accreditations /Certifications:

8. Administration & Data Management

^*9. Education

^*10. Management of Bariatric Patients

^*11. Patient Education Standards and Consent for Services

^*12. Surgical Services

^*13. Quality Assurance

^*14. Administrative Support Functions