Application for Recertification - Joint Commission on ...

1 ApplicantYour name will appear on your certificate as written for Recertification14 PaymentName: of Birth: (mm/dd/yy) _____/_____/_____(_____)FirstMiddleLastS uffixFormer name (if applicable)Home Address: _____Apt. #_____CityStateZip CodeCountryTelephone: (_____)_____ (_____)_____ Preferred E-mail_____HomeWorkSECTION A (for COA, COT, COMT, Ophthalmic Surgical Assisting, ROUB, and CDOS applicants)Clinic Name:_____Main Clinic Address:_____City: _____State:_____Zip: Telephone: _____FAX:Clinic Manager: _____ _____ s Practice Setting(Check all that apply) oPrivate, Solo oPrivate, Group: Number of Physicians o2-5 o6-10 o11 or moreoHospital Clinic or HMOoUniversity ClinicoOther:_____Employer s Main Subspecialty(Check all that apply)oCataract and IOLoComprehensive OphthalmologyoContact LensesoCornea and External DiseasesoGlaucomaoLow VisionoNeuro-OphthalmologyoOphthalmic PathologyoOphthalmic Plastic/Reconstructive SurgeryoOptical DispensingoPediatric Ophthalmology/StrabismusoRefractive SurgeryoRetina and Vitreous DiseaseoOther.

5 Responsibility Statement 2 JCAHPO's Responsibility for Certification and Recertification of Medical Personnel Performing Technical Ophthalmic Services for Ophthalmologists

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