Accreditation Application

Facilities wishing to apply for QUAD A accreditation should go to https://portal.quada.org/ to complete the
application and upload necessary documents. QUAD A will not process incomplete applications or applications
without payment. They will be returned to the facility for completion.

Date:
Accreditation program (check one): Facility Class (check one):
__ Surgical __ Procedural __ Medicare __ Oral & Maxillofacial __ Dental __ A __ B __ C-M __ C

Specialty Information (to be determined by the Facility/Medical Director)

Please list primary specialty, if more than one, add secondary specialty. List all specialties as stated on board
certification(s).
Primary specialty:
Secondary specialty:
Legal business name of facility (not DBA name):
Facility/Medical Director name:
Facility/Medical Director email address:
Office manager/head nurse name:

Previously accredited or denied accreditation by any accrediting organization?

__ No __ Previously Accredited __ Denied

Name of Accrediting Organization: ___________________________________

Please Note:
● Previous denial by QUAD A or another accreditation agency does not preclude application for accreditation. Any
facility may reapply for accreditation at any time following receipt of a denial notification.
● Failure to disclose previous accreditation, denial or revocation thereof may result in denial or loss of QUAD A
accreditation.

Alternate Facility Name (if applicable): Type of Alternate Facility Name:

__ Doing Business As (DBA) Name
__ Other (Specify):

Identify the type of organizational structure (Check one):

__ Sole Proprietor __ Business Corporation __ Limited Liability Company __ General Partnership
__ Registered Limited Liability Partnership __ Professional Corporation __ Professional Limited Liability
__ Company University Faculty Practice Corporation (501(c)(3), not-for-profit) __ Other (please specify): _______________
Is the facility entirely physician owned? Specify the Please note:
percentage that each physician owns below. QUAD A Standard 1-E-1 requires: Changes in facility
ownership must be reported to the QUAD A office within 30
__ Yes __ No
days.

1 Effective March 1, 2022

List name(s) of facility owner(s), controlling stockholder(s), or beneficial ownership. Percentages listed must equal 100%.

Name: Name:
Address: Address:
City, State, Zip: City, State, Zip:
Telephone: Telephone:
License Number: License Number:
Percent of Business Owned: Percent of Business Owned:
Name: Name:
Address: Address:
City, State, Zip: City, State, Zip:
Telephone: Telephone:
License Number: License Number:
Percent of Business Owned: Percent of Business Owned:

Facility State License Information: __ License Not Applicable

License Number: State Where Issued:
Effective Date (mm/dd/yyyy): Expiration/Renewal Date (mm/dd/yyyy):

Facility Location Information:

Address Line 1:
Address Line 2:
City/Town: State: Zip:
Telephone Number: Fax Number:
Website Address: Email Address:

Facility Contact: (We will contact this person if questions arise during the processing of this application.)
Contact Name: Email Address:
Telephone Number: Fax Number:

Physician/Surgeon Name: Medical Specialty: (as stated by board certification) State License Number:
1.

Email address:
2.
Email address:
3.
Email address:
4.
Email address:
5.
Email address:
6.

2 Effective March 1, 2022

 Email address:
7.
Email address:
8.
Email address:
9.
Email address:
10.
Email address:

The following documentation must be uploaded along with the completed application.

 A floor plan or diagram of the facility clearly labeling rooms including Operating Room, Prep/Scrub area, clean room/area,
Dirty room/area, PACU/Recovery Room, etc. (does not need to be to scale and must clearly identify each room purpose and
dimensions)
 Copy of each physician/surgeon’s State Medical License
 Copy of each physician/surgeon’s Board Certificate or letter of admissibility by the certifying board (not required for
facilities outside of the USA)
 Hospital appointment (or reappointment) letter
 Copy of each physician/surgeon’s delineation of Hospital Privileges (approved list of procedures from the hospital)
 Copy of Certificate of Incorporation (Required for applicants in the State of New York only)
 Proof that the 855B form has been processed by the carrier (Required for Medicare applicants only)
 Equipment List (Required for Medicare applicants only)
 Completed HIPAA Business Agreement signed by Medical Director.
 Completed Anesthesia Validation Form
 New York OBS Addendum (New York OBS only)

3 Effective March 1, 2022

 ANNUAL FEES FOR ACCREDITATION Survey Fees for Accreditation
Regular, Procedural or Oral & Maxillofacial
Regular, Procedural, or Oral & Maxillofacial Surgery
Number of Total number of Class Classes
$2,310 Full Survey Fee for any size facility or any class.
physicians in staff specialties A B, C-M, C
1-2 Up to 2 $869 $1,276
$853 Start-up Survey Fee. A one-time additional fee for new
3-5 Up to 2 $1,210 $1,771
facilities located in applicable states, where cases have not yet
3-5 3 or more $1,518 $2,079
been conducted under the applied for anesthesia class. This is
6-9 Up to 2 $3,839 $4,631
required if the facility is in a state that mandates accreditation
6-9 3 or more $4,136 $4,928
10 plus Up to 2 $5,401 $6,820 and is not able to do cases until accredited. Facilities located in
10 plus 3 or more $5,698 $7,755 California, New York, Florida, Indiana, Nevada, Ohio, Texas, and
Annual fee is based on the total number of physicians, the total Washington may be subject to this fee. This list is not intended
number of specialties of the physicians, and facility class. to be exhaustive, and the Startup Survey Fee may apply in other
Annual fee and survey fees are subject to change. states as regulations evolve.

Facilities may request in writing an expedited survey for an

additional $550.

All credentials must be submitted and processed prior to

survey. Talk with your accreditation specialist for details.

Regular Program Annual Fee (see schedule above): $ + $2,310 Full Survey Fee + Start-up Survey (if applicable): $853 =
Total amount of payment: $

Survey Fees for Medicare ASC Accreditation

ANNUAL
$3,630 FEES
Full Survey FeeFOR MEDICARE
for small ACCREDITATION
size facilities
Ambulatory Surgery Centers $4,730 Full Survey Fee for medium size facilities
$5,280 Full Survey Fee for large size facilities
Number of Total number Facility Class Facility and
physicians in staff of specialties A, B, C-M, C Size $3,135 Life Safety Code Survey Fee is required for all ASC
1-2 Up to 2 $1,980 Small facilities.
3-5 Up to 2 $2,475 Small
3-5 3 or more $2,783 Small $853 Startup Survey Fee. A one-time additional fee for new
6-9 Up to 2 $5,313 Medium facilities located in applicable states, where cases have not yet
6-9 3 or more $5,610 Medium been conducted under the applied for anesthesia class. This is
10 plus Up to 2 $7,491 Large required if the facility is in a state that mandates accreditation
10 plus 3 or more $8,437 Large and is not able to do cases until accredited. Facilities located in
Annual fee based on the total number of physicians, total number of California, New York, Florida, Indiana, Nevada, Ohio, Texas,
specialties of the physicians and facility class. and Washington may be subject to this fee. This list is not
Facilities may not request an expedited survey. Surveys are intended to be exhaustive, and the Startup Survey Fee may
unannounced. apply in other states as regulations evolve. State ASC licensing
Annual fee and survey fees are subject to change. laws may also impact the applicability of this fee.

The Life Safety Code fee is also applicable every third year
when the facility is due for re-survey.

Medicare ASC Annual Fee (see schedule above): $ +$ Full Survey Fee (see list above) + $3,135 Life Safety Code
Survey Fee + Start-up Survey (if applicable): $853 = Total amount of payment enclosed: $
 Payment and Billing
QUAD A will not process applications without payment. Provide your billing contact below for any questions
regarding your facility’s payment.

Billing Contact Name: ________________________________________________________________________

Billing Contact Phone: _______________________ Billing Contact Email: ______________________________

Online Payment
All accreditation and survey fees will be due before the accreditation process can continue. Payment can be
made online through the QUAD A Portal at https://portal.quada.org.

Fee and refund policy:

The first-year accreditation annual fee plus the initial survey fee is due with each accreditation application.
Additional fees will apply if special survey requests are made or for those facilities located outside the
continental USA.

If the facility withdraws its application after it has been submitted and processed, QUAD A will refund 50% of
the annual fee and 100% of the survey fee if the facility has not been surveyed. If the facility was surveyed, only
50% of the annual fee would be refunded. No refunds are issued after the facility is fully accredited.

If the facility has not confirmed a survey date within 12 months of the date of application submission, a new
application and appropriate fees are required.

In the event that a survey date is confirmed prior to the 12-month timeframe but will occur beyond that timeframe
(the confirmed survey date cannot be beyond three months after expiration) the survey cannot be postponed,
rescheduled, or cancelled. If such occurs, the facility must re-apply for accreditation and re-submit the survey and
annual fee. No refunds will be issued if the application expires.

Once an anniversary date is established upon achieving accreditation, the facility will be invoiced six months
prior to the annual anniversary date. If a facility does not pay its fees by the due date on the invoice, late fees
will be applied, and other penalties will follow. If the facility’s accreditation is revoked or terminated for any
reason, no fees will be refunded.