Print Form Clear Form Fields Endovenous Ablation Professional Privileging Application Please refer to the BCBSMA requirements for radiofrequency and laser ablation of varicose veins these services. Please return your completed, signed, and dated application to: By mail: Blue Cross Blue Shield of Massachusetts 25 Technology Place, Mailstop 03/02 Hingham, MA 02043 By fax: By email: (617) 246-3163 [email protected] Physician information MD Name: In case of questions about this MD License #: application, please contact: MD Phone # ( ) Contact phone #: NPI #: ( ) Contact email: Modality(ies) requested.  36475 Endovenous ablation therapy for incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated  36478 Endovenous ablation therapy for incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser, first vein treated  36476 Second and subsequent veins treated in a single extremity, each through separate access sites  36479 Second and subsequent veins treated in a single extremity, each through separate access sites Site of service information The facilities, physician office, and professionals conducting these procedures must be qualified to use and read ultrasound. Please complete for the site of service at which you plan to perform these procedures. Complete a separate application for each site. Site of service: Site address Site accreditation:  ICAVL (Intersocietal Commission for the Accreditation of Vascular Laboratories) Certifications; peripheral venous level  IAC (Intersocietal Accreditation Commission) Vein Center (will be required by 9/1/15) Physician and medical director documentation Applicant’s specialty:  Vascular surgery Medical director name:  Interventional radiology License #: Please attach the requested documents for the medical director and physician applicant:   CV demonstrating that the medical director and physician applicant meets BCBSMA’s requirements for training and experience, fellowships, residency, and CMEs. If CV does not show all requirements, provide documents that demonstrate that the medical director and physician applicant meet BCBSMA’s requirements For medical director, attach case log demonstrating:  For physician applicant, attach case log demonstrating: active vein care for non-ACGME postresidency or fellowship training (must be a minimum of 200 cases and must include patient outcome) or active vein care for ACGME-approved residency or fellowship. Must include a letter from the program director attesting to fellowship and accuracy of the case log. (minimum of 100 cases and must include patient outcomes)  Yes  NA  Yes  NA active vein care for non-ACGME postresidency or fellowship training (must be a minimum of 100 cases and must include patient outcome) or 50 cases for ACGME approved residency or fellowship AND  Yes  NA  Yes  NA a letter from the program director attesting to fellowship and accuracy of the case log. Please attest to each of the following. All medical staff are fully trained and certified in the current basic life support and/or advanced cardiac life support. Signature: Date: I hearby attest that all info on this application is accurate. Signature: Date: PEP-2775A (revised 11/14)