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Office Surgery Registration
Application (pdf - 107kb)- New format allows you to complete using Adobe Reader
and then print, sign and mail.
Summary of Physician Licensure Types (pdf - 24kb)
Office Surgery Registration Fee
Update
Memo (pdf - 17kb)
Section 458.309, FS (pdf - 12kb)
Section 64B-4.003, FAC
To request an application package, please use our online application request form.
Additional Documentation Needed to Register Each Physician
- Office Surgery Registration Form with an original signature for
each Surgeon
- Name and license number of any Surgeon, Physician Assistant (PA),
Certified Registered Nurse Anesthetist (CRNA), Advanced Registered
Nurse Practitioner (ARNP), or Registered Nurse (RN) at facility
- Copies of any protocols necessary for the supervision of any PA,
CRNA or ARNP.
- Name and license number of M.D. or D.O. Anesthesiologist, if
applicable
- Transfer agreement from a local hospital or staff privileges with
a delineation of procedures from a local hospital (within 30 minutes).
- Copy of current ACLS Card for Surgeon or at least one assistant
- BLS cards or ACLS cards for surgeon and staff
- The Surgeon must be able to document satisfactory completion of
training such as Board certification or Board qualification by a Board
approved by the American Board of Medical Specialties or any other
board approved by the Board of Medicine or must be able to demonstrate
to the accrediting organization or to the Department comparable
background, training and experience or must provide documentation of
staff privileges at a licensed hospital to perform the same procedure
in that hospital as that being performed in the office setting. In
addition, the surgeon must have knowledge of the principles of general
anesthesia.
- Copy of current accreditation certificate and survey, if
applicable
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