ࡱ>  c bjbjʉʉ CffX8)svq&.:Y.Y.Y.+0.Y0m0 }sssssss$tv*yrsI 0"+0IIsY.Y.sQQQIY.Y.}sQI}sQQ2i'mY.h%Jk.iss0skryK"y\'m'mymy09Q#?Dxy0y0y0ssN(y0y0y0sIIIIyy0y0y0y0y0y0y0y0y0 : North Carolina Department of Health and Human ServicesFor Official Use OnlyDivision of Health Service RegulationLicense # IF MERGEFIELD LICNO="" " ________" MERGEFIELD LICNOAS0156 ________Acute and Home Care Licensure and Certification SectionMedicare Provider #:  MERGEFIELD provider Regular Mail: 1205 Umstead Drive FID #: MERGEFIELD FID2712 Mail Service CenterPC _______ Date _____________Raleigh, N.C. 27699-2712Overnight UPS and FedEx only: 1205 Umstead DriveRaleigh, North Carolina 27603Telephone: (919) 855-4620 Total License Fee MERGEFIELD totlicfee  2020 AMBULATORY SURGICAL FACILITY LICENSE RENEWAL APPLICATION Legal Identity of Applicant: MERGEFIELD LICENSEE (Full legal name of corporation, partnership, individual, or other legal entity owning the enterprise or service.) Doing Business As (d/b/a) name(s) under which the facility or services are advertised or presented to the public: PRIMARY: IF MERGEFIELD FACILITY="" "________________________________________________________________________" MERGEFIELD FACILITYAMG Endoscopy Center________________________________________________________________________ Other: IF MERGEFIELD OBN1="" "________________________________________________________________________" MERGEFIELD OBN1Wilmington Health Ambulatory Surgery Center________________________________________________________________________ Other: IF MERGEFIELD OBN2="" "________________________________________________________________________" MERGEFIELD OBN2Mid Carolina Gastroenterology________________________________________________________________________ Facility Mailing Address: IF MERGEFIELD FADDR1="" "Street/P.O. Box: ________________________________________________" MERGEFIELD FADDR12541 North Queen StreetStreet/P.O. Box: ________________________________________________  MERGEFIELD FADDR2 IF MERGEFIELD FCITY="" "City: ______________________" MERGEFIELD FCITYKinstonCity: ______________________, IF MERGEFIELD FSTATE="" " State: ________" MERGEFIELD FSTATENC State: ________ IF MERGEFIELD FZIP="" " Zip: _______" MERGEFIELD FZIP28501 Zip: _______ Facility Site Address: IF MERGEFIELD SADDR="" "Street: ________________________________________________" MERGEFIELD SADDR2541 North Queen StreetStreet: ________________________________________________IF MERGEFIELD SCITY="" "City: ______________________" MERGEFIELD SCITYKinstonCity: ______________________, IF MERGEFIELD SSTATE="" " State: ________" MERGEFIELD SSTATENC State: ________ IF MERGEFIELD SZIP="" " Zip: ________" MERGEFIELD SZIP28501 Zip: ________County: MERGEFIELD FCOUNTYTelephone:IF MERGEFIELD FPHONE="" "(____) ___________" MERGEFIELD FPHONE(252)527-3636(____) ___________Fax:IF MERGEFIELD FFAX="" "(____) ___________" MERGEFIELD FFAX(252)523-7407(____) ___________ Administrator/Director: IF  MERGEFIELD ADMFULLNAM ="" "_____________________________________"  MERGEFIELD ADMFULLNAM Shelly A Ibegbu_____________________________________ Title: IF  MERGEFIELD ADMPOSITIO="" "_____________________________________"  MERGEFIELD ADMPOSITIOAdministrator_____________________________________ Chief Executive Officer (print or type):_______________________________________ Title: _________________________ (Designated agent (individual) responsible to the governing body (owner) for the management of the licensed facility) Name of the person to contact for any questions regarding this form: Name: ______________________________________________________ Telephone: ____________________ E-Mail:  IF  MERGEFIELD FEMAIL <> "" " MERGEFIELD FEMAIL pcarmichael@boice-willis.com" "______________________________________________________" ______________________________________________________ For questions regarding this page, please contact Azzie Conley at (919) 855-4646. In accordance with Session Law 2013-382 and 10A NCAC 13C .0103(13) and 13C .0301(d), on the license renewal application provided by the Division, the facility shall provide to the Division the direct website address to the facilitys financial assistance policy. Please use Form 990 Schedule B and/or Schedule H as a reference. Please provide the main website address for the facility: ______________________________________________________________________________ In accordance with 131E-214.4(a) DHSR can no longer post a link to internet Websites to demonstrate compliance with this statute. Please provide the website address and/or link to access the facilitys charity care policy and financial assistance policy: ______________________________________________________________________________________ Also, please attach a copy of the facilitys charity care policy and financial assistance policy: Feel free to email the copy of the facilitys charity care policy to: DHHS.DHSR.ASC.CharityCare.Policy@dhhs.nc.gov. Please provide the following financial assistance data. All responses can be located on Form 990 and/or Form 990 Schedule H. Contribution, Gifts, Grants and other similar Amounts (Form 990; Part VIII 1(h))Annual Financial Assistance at Cost (Form 990; Schedule H Part I, 7(a)(c))Bad Debt Expense (Form 990; Schedule H Part III, Section A(2))Bad Debt Expense Attributable to Patients eligible under the organization's financial assistance policy (Form 990; Schedule H Part III, Section A(3)) AUTHENTICATING SIGNATURE: this attestation statement is to validate compliance with GS 131E-91 as evidenced through 10A NCAC 13C .0301 and all requirements set forth to assure compliance with fair billing and collection practices. Signature: ____________________________________________Date:_____________________ Print Name of Approving Official: _____________________________________________________________________________________ ITEMIZED CHARGES: Licensure Rule 10 NCAC 13C .0205 requires the Applicant to provide itemized billing. Indicate which method is used: _____ a. The facility provides a detailed statement of charges to all patients. _____ b. Patients are advised that such detailed statements are available upon request. Ownership Disclosure (Please fill in any blanks and make changes where necessary.) 1. What is the name of the legal entity with ownership responsibility and liability? Owner:IF MERGEFIELD OWNCONAME="" "_______________________________________________________" MERGEFIELD OWNCONAMEAtlantic Medical Group,PC_______________________________________________________National Provider Identifier (NPI):Street/Box:IF MERGEFIELD OWNADDR1="" "_______________________________________________________" MERGEFIELD OWNADDR12541 North Queens Street_______________________________________________________City: IF MERGEFIELD OWNCITY="" "___________________" MERGEFIELD OWNCITYKinston___________________ State: IF MERGEFIELD OWNSTATE="" "____" MERGEFIELD OWNSTATENC____ Zip: IF MERGEFIELD OWNZIP="" "____________" MERGEFIELD OWNZIP28501____________Telephone:IF MERGEFIELD OWNPHONE="" "(____) ___________" MERGEFIELD OWNPHONE(252)527-3636(____) ___________ Fax: IF MERGEFIELD OWNFAX="" "(____) ___________" MERGEFIELD OWNFAX(252)523-7407(____) ___________CEO:IF MERGEFIELD SROFFICER="" "_______________________________________________________" MERGEFIELD SROFFICERDr. Eric Ibegbu, President_______________________________________________________ Is your facility part of a Health System? [i.e., are there other ambulatory surgical facilities, hospitals, nursing homes, home health agencies, etc. owned by your facility, a parent company or a related entity?] Yes No If Yes, name of Health System _____________________________________________________ a. Legal entity is: IF  MERGEFIELD ownnfprof  = "False" " X For Profit" " For Profit"  For Profit IF  MERGEFIELD ownnfprof  = "True" " X Not For Profit" " Not For Profit"  Not For Profitb. Legal entity is:IF MERGEFIELD OWNOWNTYPE="CORP" " X Corporation" " Corporation" Corporation IF MERGEFIELD OWNOWNTYPE="LLC" "_X_ Limited Liability Corporation (LLC)" " ____ Limited Liability Corporation (LLC)" ____ Limited Liability Corporation (LLC)IF MERGEFIELD OWNOWNTYPE="PART" " X Partnership" " Partnership" Partnership IF MERGEFIELD OWNOWNTYPE="PROP" " X Proprietorship" " Proprietorship" Proprietorship IF MERGEFIELD OWNOWNTYPE="LLP" " X Limited Liability Partnership (LLP)" "____ Limited Liability Partnership (LLP)"____ Limited Liability Partnership (LLP) IF MERGEFIELD OWNOWNTYPE="GOVMT" " X Government Unit" " Government Unit" Government UnitDoes the above entity (individual, partnership, corporation, etc.) lease the building from which services are offered? IF  MERGEFIELD ownleasebl  = "False" " Yes X No" " X Yes No"  Yes No If "Yes", name and address of building owner: IF  MERGEFIELD ownbldown ="" ""  MERGEFIELD ownbldown ESI Investment , LLC 2. Is the business operated under a management contract?  IF  MERGEFIELD mgmtconame  > "" " X Yes No" " Yes X No"  Yes _ No If Yes, name and address of the management company Name:IF MERGEFIELD MGMTCONAME="" "____________________________________________________________________" MERGEFIELD MGMTCONAMESurgical Care Affiliates Inc____________________________________________________________________Street/Box:IF MERGEFIELD MGMTADDR1="" "____________________________________________________________________" MERGEFIELD MGMTADDR1596 Brookwood Village____________________________________________________________________MERGEFIELD MGMTADDR2City:IF MERGEFIELD MGMTCITY="" "______________________" MERGEFIELD MGMTCITYBirmingham______________________ State: IF MERGEFIELD MGMTSTATE="" "____________" MERGEFIELD MGMTSTATEAL____________ Zip: IF MERGEFIELD MGMTZIP="" "____________" MERGEFIELD MGMTZIP35209____________Telephone:IF MERGEFIELD MGMTPHONE="" "(____) ___________" MERGEFIELD MGMTPHONE(205)545-2572(____) ___________ 3. Accreditation: (Please fill in any blanks and change where necessary. If you are deemed, please attach a copy of the deeming letter from the accrediting agency. If surveyed within the last twelve (12) months, attach or mail a copy of your accreditation report and grid to this office. If applicable, attach copy of plan of correction.) a. Is this facility TJC accredited? IF  MERGEFIELD JCAHO \* Upper ="TRUE" " X Yes _____ No" "_____ Yes X No" _____ Yes _ No Expiration Date: ____________ b. Is this facility AAAHC accredited? _____ Yes _____ No Expiration Date: ____________ c. Is this facility AAAASF accredited? _____ Yes _____ No Expiration Date: ____________ d. Is this facility DNV accredited? _____ Yes _____ No Expiration Date: ____________ e. Are you a Medicare deemed _____ Yes _____ No provider? Reporting Period: All responses should pertain to October 1, 2018 to September 30, 2019. Meals: a. Are meals provided for patients? ____ Yes ____ No b. If Yes, describe arrangements for this service: _________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ c. If Yes, what is the date of the last sanitation inspection: __________________________________ d. Date of last Fire Marshal inspection: _______________________________________________ e. Date inspected by the Health Department: ____________________________________________  Hours: Indicate the number of hours (e.g., 8 hrs) that the facility is routinely open for surgery and recovery each day: Enter a zero (0) if not open SundayMondayTuesdayWednesdayThursdayFridaySaturday Anesthesia: a. Qualifications of persons administering anesthesia (check one or more) ____ Anesthesiologist ___ Other M.D. ____ CRNA ____ RN ____ DDS b. Name of Anesthesia Group: ___________________________________________________ Provide information regarding the use and storage of flammable anesthesia: ______________________ ________________________________________________________________________ ________________________________________________________________________ Other Information Needed: a. Name of laboratory and pathology services utilized: ______________________________________ _________________________________________________________________________ b. Name of hospital with which transfer agreement has been made: ______________________________ _________________________________________________________________________ _________________________________________________________________________ c. Describe arrangements for emergency transportation of patients from the facility: _________________________________________________________________________ _________________________________________________________________________ d. Do you provide recovery care services overnight? ____ Yes ____ No e. Are surgical abortions performed in this facility? ____ Yes ____ No If Yes, please give the number of abortions performed during the reporting period: ____________ f. Are medical abortions performed in this facility? ____ Yes ____ No If Yes, please give the number of abortions performed during the reporting period: _________________ Composition of Surgical Staff: Please indicate below the number of physicians credentialed to perform surgery in your ambulatory surgical program during the reporting period. Surgical SpecialistNumberAnesthesiologistDentistGastroenterologistGeneral SurgeonGynecologistNeurologistObstetricianOphthalmologistOral SurgeonOrthopedic SurgeonOtolaryngologistPlastic SurgeonPodiatristThoracic SurgeonUrologistVascular SurgeonOtherTotal: Name of Chief of Staff: ______________________________________________________________ Name of Director of Nursing: _________________________________________________________ Surgical Operating Rooms; Procedure Rooms; and Gastrointestinal Endoscopy Rooms, Cases and Procedures: 20 Most Common Outpatient Surgical Cases Table - Enter the number of surgical cases performed only in licensed operating rooms and / or licensed endoscopy room by the top 20 most common outpatient surgical cases in the table below by CPT code. Count each patient undergoing surgery as one case regardless of the number of surgical procedures performed while the patient was having surgery. CPT CodeDescriptionCases29827Arthroscopy, shoulder, surgical; with rotator cuff repair29880Arthroscopy, knee, surgical; with meniscectomy (medial and lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed29881Arthroscopy, knee, surgical; with meniscectomy (medial or lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed42820Tonsillectomy and adenoidectomy; younger than age 1242830Adenoidectomy, primary; younger than age 1243235Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)43239Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple43248Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guide wire followed by dilation of esophagus over guide wire43249Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus (less than 30 mm diameter)45378Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)45380Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple45384Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery45385Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique62311Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)64483Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or computed tomography); lumbar or sacral, single level64721Neuroplasty and/or transposition; median nerve at carpal tunnel66821Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (e.g., YAG laser) (one or more stages)66982Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage66984Extracapsular cataract removal with insertion of intraocular lens prosthesis (stage one procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification)69436Tympanostomy (requiring insertion of ventilating tube), general anesthesia Total Existing Licensed Surgical Operating Rooms: # ________ A Surgical Operating Room is defined as a room used for the performance of surgical procedures requiring one or more incisions and that is required to comply with all applicable licensure codes and standards for an operating room (G.S. 131E-146(1c)). Do not include unlicensed procedure rooms or GI endoscopy rooms listed in Part B. or C., which follow. Gastrointestinal Endoscopy Rooms, Procedures, and Cases: Report the number of Gastrointestinal Endoscopy rooms, and the Endoscopy cases and procedures perfomed during the reporting period, in GP Endoscopy Rooms and in any other location. Total Licensed Gastrointestinal Endoscopy Rooms: #  SHAPE \* MERGEFORMAT  GI Endoscopies*PROCEDURESCASESTOTAL CASESPerformed in Licensed GI Endoscopy RoomsNOT Performed in Licensed GI Endoscopy RoomsTOTAL CASES must match total reported on Page 12 (Patient Origin GI Endoscopy Cases) ( *As defined in 10A NCAC 14C .3901 Gastrointestinal (GI) endoscopy procedure means a single procedure, identified by CPT code or ICD-9-PCS [ICD-10-PCS] procedure code, performed on a patient during a single visit to the facility for diagnostic or therapeutic purposes. Procedure Rooms (Excluding Operating Rooms and Gastrointestinal Endoscopy Rooms) Report rooms, which are not licensed as operating rooms or GI endoscopy rooms, but that are used for performance of surgical procedures other than Gastrointestinal Endoscopy procedures. Total Procedure Rooms: # ___________________ D. Total recovery room beds: # __________________ Surgical and Non-Surgical Cases Surgical Cases by Specialty Area - Enter the number of surgical cases performed only in licensed operating rooms by surgical specialty area in the chart below. Count each patient undergoing surgery as one case regardless of the number of surgical procedures performed while the patient was having surgery. Categorize each case into one specialty area the total number of surgical cases is an unduplicated count of surgical cases. Please do not include abortion procedures on this table. Count all surgical cases performed only in licensed operating rooms. The total number of surgical cases must match the total number of patients listed in the Patient Origin Table on page 11. Surgical Specialty AreaCasesCardiothoracic General SurgeryNeurosurgeryObstetrics and GYN OphthalmologyOral Surgery/DentalOrthopedicsOtolaryngologyPlastic SurgeryPodiatryUrologyVascularOther Surgeries (specify) Other Surgeries (specify) Total Surgical Cases Performed Only in Licensed ORs (must match total on page 11) Number of surgical procedures performed in unlicensed Procedure Rooms _____________ Non-Surgical Cases by Category - Enter the number of non-surgical cases by category in the table below. Count each patient undergoing a procedure or procedures as one case regardless of the number of non-surgical procedures performed. Categorize each case into one non-surgical category the total number of non-surgical cases is an unduplicated count of non-surgical cases. Count all non-surgical cases, including cases receiving services in operating rooms or in any other location. Non-Surgical CategoryCasesEndoscopies OTHER THAN GI Endoscopies Performed in Licensed GI Endoscopy Room NOT Performed in Licensed GI Endoscopy RoomOther Non-Surgical CasesPain ManagementCystoscopyYAG LaserOther (specify) Average Operating Room Availability and Average Case Times: For questions regarding this page, please contact Healthcare Planning at 919-855-3865. Based on your facilitys experience, please complete the table below by showing the averages for all licensed operating rooms in your facility. Healthcare Planning uses this data in the operating room need methodology. Average case times should be calculated, not estimated. When reporting case times, be sure to include set-up and clean-up times. Average Hours per Day Routinely Scheduled for Use Per Room*Average Number of Days per Year Routinely Scheduled for UseAverage Case Time ** in Minutes for Ambulatory Cases * Use only Hours per Day routinely scheduled when determining the answer. Example: A facility has 3 ORs: 2 are routinely scheduled for use 8 hours per day, and 1 is routinely scheduled for use 9 hours per day. 2 rooms x 8 hours = 16 hours 1 room x 9 hours = 9 hours Total hours per day 25 hours 25 hours divided by 3 ORs = 8.3 Average Hours per day Routinely Scheduled for Use Per Room ** Case Time = Time from Room Set-up Start to Room Clean-up Finish. Definition 2.4 from the Procedural Times Glossary of the AACD, as approved by ASA, ACS, and AORN. NOTE: This definition includes all of the time for which a given procedure requires an OR. It allows for the different duration of Room Set-up and Room Clean-up Times that occur because of the varying supply and equipment needs for a particular procedure. Reimbursement Source Primary Payer SourceNumber of CasesSelf PayCharity CareMedicare*Medicaid*Insurance*Other (Specify)TOTAL * Including any managed care plans. Definition of Health System for Operating Room Need Determination Methodology If this is a GI Endoscopy Only facility, do not complete the Health System section. The Operating Room need determination methodology uses the following definition of health system that differs from the definition on page 3 of the License Renewal Application. (Note that for most facilities, the health system entered here will be the same health system entered on page 3, but it may not be. Please read this definition carefully.) A health system includes all licensed health service facilities located in the same county that are owned or leased by: the same legal entity (i.e., the same individual, trust or estate, partnership, corporation, hospital authority, or the State or political subdivision, agency or instrumentality of the State); or the same parent corporation or holding company; or a subsidiary of the same parent corporation or holding company; or a joint venture in which the same parent, holding company, or a subsidiary of the same parent or holding company is a participant and has the authority to propose changes in the location or number of ORs in the health service facility. A health system consists of one or more health service facilities. Based on the above definition, is this facility in a health system? _______ Yes _______ No If so, name of health system: _____________________________________________________________ Imaging Procedures 20 Most Common Outpatient Imaging Procedures Table - Enter the number of the top 20 common imaging procedures performed in the ambulatory surgical center in the table below by CPT code. CPT CodeDescriptionProcedures70450Computed tomography, head or brain; without contrast material70486Computed tomography, facial bone; without contrast material70551Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material 70553Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material followed by contrast material(s) and further sequences71020Radiologic examination, chest; two views, frontal and lateral71250Computed tomography, thorax; without contrast material(s)71260Computed tomography, thorax; with contrast material(s)71275Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing72100Radiologic examination, spine, lumbosacral; two or three views72110Radiologic examination, spine, lumbosacral; minimum of four views72125Computed tomography, cervical spine; without contrast material72141Magnetic resonance (e.g., proton) imaging, spine cervical without contrast material 72148Magnetic resonance (e.g., proton) imaging, spine lumbar without contrast material 73221Magnetic resonance (e.g., proton) imaging, upper joint (e.g. shoulder, elbow, wrist) extremity without contrast material 73630Radiologic examination, foot; complete, minimum of three views73721Magnetic resonance (e.g., proton) imaging, lower joint (e.g. knee, ankle, mid-hind foot, hip) extremity without contrast material74000Radiologic examination, abdomen; single anteroposterior view74176Computed tomography, abdomen and pelvis; without contrast material74177Computed tomography, abdomen and pelvis; with contrast material(s)74178Computed tomography, abdomen and pelvis; with contrast material(s) followed by contrast material  Patient Origin -Ambulatory Surgical Services In an effort to document patterns of utilization of ambulatory surgical services in North Carolinas licensed freestanding ambulatory surgical facilities, you are asked to provide the county of residence for each patient (as reported on page 8) who had Ambulatory Surgery in your facility during the reporting period. Total number of patients must match the total number of surgical cases from the Surgical Cases by Specialty Area table on page 8. CountyPRIVATE  No. of Patients CountyNo. of Patients County No. of Patients 1. Alamance 37. Gates 73. Person 2. Alexander 38. Graham 74. Pitt 3. Alleghany 39. Granville 75. Polk 4. Anson 40. Greene 76. Randolph 5. Ashe 41. Guilford 77. Richmond 6. Avery 42. Halifax 78. Robeson 7. Beaufort 43. Harnett 79. Rockingham 8. Bertie 44. Haywood 80. Rowan 9. Bladen 45. Henderson 81. Rutherford 10. Brunswick 46. Hertford 82. Sampson 11. Buncombe 47. Hoke 83. Scotland 12. Burke 48. Hyde 84. Stanly 13. Cabarrus 49. Iredell 85. Stokes 14. Caldwell 50. Jackson 86. Surry 15. Camden 51. Johnston 87. Swain 16. Carteret 52. Jones 88. Transylvania 17. Caswell 53. Lee 89. Tyrrell 18. Catawba 54. Lenoir 90. Union 19. Chatham 55. Lincoln 91. Vance 20. Cherokee 56. Macon 92. Wake 21. Chowan 57. Madison 93. Warren 22. Clay 58. Martin 94. Washington 23. Cleveland 59. McDowell 95. Watauga 24. Columbus 60. Mecklenburg 96. Wayne 25. Craven 61. Mitchell 97. Wilkes 26. Cumberland 62. Montgomery 98. Wilson 27. Currituck 63. Moore 99. Yadkin 28. Dare 64. Nash100. Yancey 29. Davidson 65. New Hanover 30. Davie 66. Northampton101. Georgia 31. Duplin 67. Onslow102. South Carolina 32. Durham 68. Orange103. Tennessee 33. Edgecombe 69. Pamlico104. Virginia 34. Forsyth 70. Pasquotank105. Other States 35. Franklin 71. Pender106. Other/Unknown 36. Gaston 72. Perquimans Total No. of Patients Patient Origin Gastrointestinal (GI) Endoscopy Services In an effort to document patterns of utilization of gastrointestinal endoscopy services in North Carolinas licensed freestanding ambulatory surgical facilities, you are asked to provide the county of residence for each patient who had a Gastrointestinal Endoscopy in your facility during the reporting period. Total number of patients must match GI Endoscopy Cases from the Gastrointestinal Endoscopy Rooms, Procedures, and Cases table on page 7. CountyPRIVATE  No. of Patients CountyNo. of Patients County No. of Patients 1. Alamance 37. Gates 73. Person 2. Alexander 38. Graham 74. Pitt 3. Alleghany 39. Granville 75. Polk 4. Anson 40. Greene 76. Randolph 5. Ashe 41. Guilford 77. Richmond 6. Avery 42. Halifax 78. Robeson 7. Beaufort 43. Harnett 79. Rockingham 8. Bertie 44. Haywood 80. Rowan 9. Bladen 45. Henderson 81. Rutherford 10. Brunswick 46. Hertford 82. Sampson 11. Buncombe 47. Hoke 83. Scotland 12. Burke 48. Hyde 84. Stanly 13. Cabarrus 49. Iredell 85. Stokes 14. Caldwell 50. Jackson 86. Surry 15. Camden 51. Johnston 87. Swain 16. Carteret 52. Jones 88. Transylvania 17. Caswell 53. Lee 89. Tyrrell 18. Catawba 54. Lenoir 90. Union 19. Chatham 55. Lincoln 91. Vance 20. Cherokee 56. Macon 92. Wake 21. Chowan 57. Madison 93. Warren 22. Clay 58. Martin 94. Washington 23. Cleveland 59. McDowell 95. Watauga 24. Columbus 60. Mecklenburg 96. Wayne 25. Craven 61. Mitchell 97. Wilkes 26. Cumberland 62. Montgomery 98. Wilson 27. Currituck 63. Moore 99. Yadkin 28. Dare 64. Nash100. Yancey 29. Davidson 65. New Hanover 30. Davie 66. Northampton101. Georgia 31. Duplin 67. Onslow102. South Carolina 32. Durham 68. Orange103. Tennessee 33. Edgecombe 69. Pamlico104. Virginia 34. Forsyth 70. Pasquotank105. Other States 35. Franklin 71. Pender106. Other/Unknown 36. Gaston 72. Perquimans Total No. of Patients This license renewal application must be completed and submitted to the Acute and Home Care Licensure and Certification Section, Division of Health Service Regulation prior to the issuance of a 2020 Ambulatory Surgical Facility license. AUTHENTICATING SIGNATURE: The undersigned submits application for licensure subject to the provisions of G.S. 131E-147 and Licensure Rules 10A NCAC 13C adopted by the Medical Care Commission, and certifies the accuracy of this information. Signature: _______________________________________________Date:_________________________ Print Name & Title of Approving Official: _____________________________________________________________________________________________________ Please be advised, the licensure fee must accompany the completed application and be submitted to the Acute and Home Care Licensure and Certification Section, Division of Health Service Regulation, prior to the issuance of an ambulatory surgical facility license.     2020 License Renewal Application for Ambulatory Surgical Facility:License No:  MERGEFIELD LICNO  MERGEFIELD FACILITY Facility ID:  MERGEFIELD FID All responses should pertain to October 1, 2018 thru September 30, 2019.  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