1. Basic Information:

*Type of Applicant Center:

*2. Business Model

Business Model: ( You can check more than one )

note : atleast 1 need to be selected.

3. Identifying Information


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

COTE Compliance Coordinator

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 :

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


Name of License Start Date End Date Current

(+) add more Licenses


Name of Certificate Start Date End Date Current

(+) add more Certificate

8. Administration & Data Management

*9. Education

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

Name of HCP AABC certification no

(+) add more

The number of Health Care Professionals on the Interdisciplinary Team who will enroll in the AABC Board Certification in Bariatric Science Program in the next year.

*10. Management of Bariatric Patients

*11. Patient Education Standards and Consent for Services

*12. Surgical Services

Mention type of surgery services provided in your facility( If applicable):

Check each of the services you currently provide:

*13. Quality Assurance

Indicate how often the QI Plan is updated:

*14. Administrative Support Functions

Check the statements provided below ensuring that the applicant will comply with requirements relating to Eligibility Determination:

Authorized Signature of Applicant (from section 2 (leadership) of this application)

For additional assistance with your application or any further guidance please contact COTE committee at: e-mail: , Tel: 1-866-284-3682