Similar documents
STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS LANSING

STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS LANSING

LeadingAge Michigan SNF Regulatory Day. State Licensure & Federal Certification Update

Presented by: Department of Health Care Services Provider Enrollment Division (PED) Wednesday, January 16, 2013

STATE OF MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES LANSING

CI C Wolverine Secure Treatment Center

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY

Michelle McFarland, HFE NEII

STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS LANSING

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 3. NAME AND ADDRESS OF FACILITY

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY

Gary Nederhoff, Unit Supervisor

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00712

TB Testing Requirements for Licensed Facilities. Bureau of Community & Health Systems (BCHS) Presenters

Center for Medicaid and State Operations/Survey and Certification Group

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00858

State of Michigan DEPARTMENT OF HEALTH AND HUMAN SERVICES

Mary Heim, HPR-Social Work Specialist 09/03/2013

Protecting, Maintaining and Improving the Health of Minnesotans

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 3. NAME AND ADDRESS OF FACILITY

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY

Patricia Halverson, Unit Supervisor

Patricia Halverson, Unit Supervisor

Brenda Fischer, Unit Supervisor 09/13/2012 Colleen B. Leach, Program Specialist 09/18/2012

ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE CHAPTER 610-X-9 ADVANCED PRACTICE NURSING TABLE OF CONTENTS

CHAPTER 6: CREDENTIALING PROCEDURES

Timothy Rhonemus, NFE NEII

Jessica Sellner, HFE, NEII 11/23/2011 Colleen B. Leach, Program Specialist 01/13/2012

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00351

James Anderson, State Fire Marshall

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00166

Requirements for Provider Type 21 Case Manager

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00940

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00719

Aetna Better Health Hospital Credentialing Packet Table of Contents

Re: CMS 3244 P (42 CFR Parts 482 and 485: Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation)

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00695

AMBULATORY SURGERY FACILITY GENERAL INFORMATION

Federally Qualified Health Center

07/23/ /21/2013 (L20)

State of Michigan DEPARTMENT OF HUMAN SERVICES

Medicare Program; Announcement of the Reapproval of the Joint Commission as an

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00903

ADM File No [Deletions are indicated by strikeover and insertions by underline.]

Health Careers Scholarship Application Packet

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00861

Lou Anne Page, HFE NE II

Jurisdiction Nebraska. Retirement Date N/A

Kathleen Lucas, Unit Supervisor

Hospital Crosswalk. Medicare Hospital Requirements to 2012 Joint Commission Hospital Standards & EPs

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00598

Hospital Crosswalk. Medicare Hospital Requirements to 2017 Joint Commission Hospital Standards & EPs. Joint Commission Equivalent Number EP 2 EP 1

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00360

C A L I F O R N I A L A B O R AT O RY P E R S O N N E L

Point of Care Testing. BOPCC May 31, 2011 Beatrice O Keefe, Chief Laboratory Field Services California Department of Public Health

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 3. NAME AND ADDRESS OF FACILITY

CLIA S NEW IQCP SEABB. March 19, Linda Sigg, MT(ASCP)SBB,CQA(ASQ) Staff Lead Assessor, Accreditation, AABB

State of Michigan Civil Service Commission Capitol Commons Center, P.O. Box Lansing, MI POSITION DESCRIPTION

Defines adult foster care and license categories Defines licensee

PERSONNEL REQUIREMENTS. March 9, 2018

AgeWell New York Provider Relations 1991 Marcus Avenue Suite M201 Lake Success, NY 11042

3. Five years of verified work experience in reinforced concrete construction inspection.

BCBSNC Provider Application for Participation

Cheryl Johnson, HFE NEII


Network Monitoring and Management

Hospital Credentialing Application

Medicare Program; Announcement of the Approval of the American Association for

Practitioners may be recredentialed at any time, but in no circumstance longer than a 36 month period.

NURSING Credentials Major Description

Point of Care Testing

ESAR-VHP Volunteers in Indiana. Rachel Miller ESAR-VHP, Program Director Indiana State Department of Health

The CLIA regulations..

24 th International President Director, Great Lakes Region Geraldine G. Peeples Scholarship Chair, Great Lakes Region

II. HOW NURSING FACILITIES ARE REGULATED

POSITION DESCRIPTION

ANCILLARY/FACILITY APPLICATION CREDENTIALING / RE-CREDENTIALING

Printed copies are for reference only. Please refer to the electronic copy for the latest version.

Internal Lab Inspections: Are You Inspection Ready? Presented by: Jeanne Mumford, MT(ASCP) Manager, Point of Care Testing, JHM

You re Enrolled in PQSR 2004

ASSEMBLY BILL No. 940

Ohio Home Care Waiver Provider Application Process

CONTINUING EDUCATION REQUIREMENTS FOR MICHIGAN NURSES

CONTINUING EDUCATION REQUIREMENTS FOR MICHIGAN NURSES

CLIA & Individualized Quality Control Plan (IQCP) Judith Yost Director Division of Laboratory Services

SHAWNEE COMMUNITY COLLEGE ULLIN, ILLINOIS ADMISSION PACKET

PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS

HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION

PROGRAM GUIDE - UNIVERSITY CLIA REGISTERED LABORATORIES COMPLIANCE COMMITTEE

MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES NOTICE OF PROPOSED POLICY

This letter is to let you know that you are due for re-credentialing as a participating provider for AmeriHealth Caritas Louisiana of Louisiana.

Daralyn Hassan, MS, MT(ASCP) April 3rd, 2014 CLIA

Nursing Student Loan Forgiveness Program Application Package

HOSPICE CONTRACTING CHECKLIST FOR INPATIENT SERVICES, RESPITE CARE AND VENDOR AGREEMENTS

CAP Most Frequent Deficiencies and How to Avoid Them. March 11, 2015

DEPARTMENT OF HEALTH & HUMAN SERVICES WARNING LETTER. (b) (4) clinical investigation (Protocol entitled A Phase II, Multicenter,

College of American Pathologists 325 Waukegan Road, Northfield, Illinois Advancing Excellence

Alert. Changes to Licensed Scope of Practice of Physician s Assistants in Michigan. msms.org. Participating Physician. Practice Agreement

Values Accountability Integrity Service Excellence Innovation Collaboration

Transcription:

RICK SNYDER GOVERNOR STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF HEALTH CARE SERVICES STEVE ARWOOD DIRECTOR June 19, 2014 Amerathon, LLC dba American Health Associate 39205 Country Club Drive Suite C-30 Farmington Hills, MI 48331 Dear Director: RE: CLIA #23D2045786 On June 18, 2014, we received a CMS-116 CLIA Application from you requesting the changes listed below. These changes were entered into the CMS database on June 19, 2014. Previous Data Facility Name: Suburban Medical Laboratory, Inc dba Medlab Current Data Amerathon, LLC dba American Health Associate Federal tax i.d.#: 34-1170859 46-4810201 Mailing Address: N/A 671 Ohio Pike Suite K Cincinnati, OH 45245 Your current CLIA Certificate of Compliance is valid through May 23, 2015. Please contact this office at (517) 241-2648 should you have further questions. For additional information about CLIA topics, please go to: http://www.cms.hhs.gov/clia. Sincerely, Michelle Roepke, BS, MT(ASCP) Manager - Laboratory Improvement Section Division of Licensing and Certification LARA Bureau of Health Care Services LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. 611 W. Ottawa P.O. BOX 30664 LANSING, MICHIGAN 48909 www.michigan.gov/bhcs (517) 241-4160

October 15, 2014 Denise Kamps, Director Amerathon, Llc 521 E County Line Rd Greenwood, IN 46143 CLIA# 15D2047655 Dear Director: This letter is to confirm receipt of correspondence and/or information dated October 1, 2014 regarding the following change(s) within your laboratory: Current Name: Amerathon, LLC DBA American Health Associate Current Tax ID: 46-4810201 Current Telephone No.: (317)474-8543 Current Fax No.: (317)859-3289 The above change(s) have been made in the CLIA database. While we do appreciate the notification and information submitted, the Indiana State Department of Health (ISDH) does not have administrative authority to issue a new CLIA certificate at this time for the changes made, i.e., name, laboratory director, address, etc. Please use this letter as verification of your change. FOR FUTURE CHANGES ONLY: Please notify this office by submitting a new Clinical Laboratory Improvement Amendments (CLIA) Application for Certification Form CMS 116 and Enclosure I for the following changes: 1. Status or Certificate Change (6 months after termination of certificate) 2. Reinstatement of CLIA Certificate 3. Change of director for Provider Performed Microscopy Procedure (PPM) Certificates, and Certificate of Compliance (Also include qualification information for the director: license, diploma, transcripts, board certification, additional training, etc) Please notify this office by submitting a new Clinical Laboratory Improvement Amendments (CLIA) Application for Certification Form CMS 116 and Enclosure A for the following changes: 1. Change of Ownership

2. Change of Tax ID Please notify this office by submitting a new Clinical Laboratory Improvement Amendments (CLIA) Application for Certification Form CMS 116 for the following changes: 1. Multi site exception (for not for profit status request you must provide documentation of not for profit status for each location. 2. Specialty/ Subspecialty change for Certificate of Compliance. (For Certificate of Accreditation please notify your Accreditation Organization.) Please notify this office by submitting a letter on your letter head and signed by your director, that includes your CLIA number and the name of your facility for the following changes: 1. Change of Director Certificate of Waiver 2. Change of Director Certificate of Accreditation (must also include approval of director change from your Accreditation Organization.) 3. Status Change to Certificate of Waiver 4. Change of Name of Laboratory 5. Change of Location (Physical Address and Mailing Address) 6. Total Volume Change 7. Telephone and fax number change 8. Reinstatement of certificate (within 6 months of termination) 9. Change in Accreditation Organization (with approval letter from new Accreditation Organization) 10. Voluntary Closure/Termination of CLIA Certificate 11. Personnel changes- Technical Supervisor for Certificate of Compliance If you have any questions, require any forms, or need further information, please address your concerns in e-mail to lswitzer@isdh.in.gov or feel free to call (317) 233-7495 or the numbers below or visit our web site at http://www.in.gov/isdh/25360.htm. Sincerely yours, Lorraine Switzer Program Director CLIA/Blood Ctr/Rehab/Portable X-Ray Programs Acute Care Division Indiana State Department of Health (317) 233-7502 (317) 233-7157 Fax