PROVIDER TYPE PROFILE
PROVIDER
TYPE
E1 INDEPENDENT TESTING FACILITIES
REIMBURSE-
MENT TYPE
02 FEE FOR SERVICE
EFFECTIVE 11-01-03
CATEGORIES OF SERVICE LICENSE/CERTIFICATION
MANDATORY 01 MEDICINE MUST MEET ONE OF THE FOLLOWING
SETS OF CRITERIA:
(1) LICENSED BY ADHS AS AN
OUTPATIENT TREATMENT CENTER
AND IS ACCREDITED BY THE
AMERICAN ACADEMY OF SLEEP
MEDICINE.
(2) HAS A MEDICAL DIRECTOR WHO IS
CERTIFIED BY THE AMERICAN
BOARD OF SLEEP MEDICINE (MUST
SUBMIT CERTIFICATION), AND HAS
A MANAGING SLEEP TECHNICIAN
WHO IS REGISTERED BY THE
BOARD OF REGISTERED
POLYSOMNOGRAPHIC
TECHNOLOGIST. PROOF OF
REGISTRATION IS REQUIRED.
(3) FOR SLEEP EEGS ONLY, THE
PROVIDER MUST HAVE A
PHYSICIAN WHO IS A BOARD
CERTIFIED NEUROLOGIST. .
PROOF OF SPECIALITY
CERTIFICATION IS REQUIRED.
ADHS LICENSURE IS NOT
REQUIRED FOR THE PROVIDER.
THE PROVIDER IS REGISTERED
UNDER THE PHYSICIAN PROVIDER
TYPE.
MANDATORY
MANDATORY
OPTIONAL
OPTIONAL
SPECIAL INSTRUCTIONS: The owner/provider is responsible for maintaining and providing upon request
copies of registration and certification. By signing below you are indicating that the requirements stated
above will be kept on file and made available on request.
NAME OF
PROVIDER_______________________________________________TITLE________________________
SIGNATURE______________________________________________DATE________________________
