Common use of Annual Reporting Template Clause in Contracts

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (April 1 to March 31) Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (from April 1 1st 2012 to March 31) 31st 2017. Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Title Professiona BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Name Name l Issue Update Issue Update Issued Update Designation d d /Title "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (April 1 to March 31) from July 1, 2013. Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (from April 1 1st 2012 to March 31) 31st 2017. Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Title Professiona l Designation /Title BCLS Issued Issue d BCLS Update ACLS Issued Issue d ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each from April 1, 2018 and the following fiscal year (April 1 to years ending March 31) . Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Designation/Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (from April 1 to March 31) 31 20 . Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for from the effective date to March 31 each fiscal year (April 1 to March 31) Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category CPSM COPY Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Designation/Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update CPSM COPY "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.. CPSM COPY

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (April 1 to March 31) from July 19th, 2010. Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 "Section 11.5" of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (April 1 to March 31) from May 1, 2019. Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Designation/Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" Section 8.4 of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year under contract (April 1 to March 31) 31st). Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Title Professiona BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Name Name l Issue Update Issue Update Issued Update Designation d d /Title "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (from April 1 to March 31) . Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Designation/Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for from the effective date to March 31 each fiscal year (April 1 to March 31) year. Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Designation/Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (April 1 to March 31) ). Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Designation/Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (April 1 to March 31) ). Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Designation/Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for from the effective date to March 31 each fiscal year (April 1 to March 31) Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Designation/Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for from the effective date to March 31 each fiscal year (April 1 to March 31) Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues services provided by your Facility. for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Designation/Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (April 1 to March 31) from July 1, 2019 until June 30, 2024. Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Designation/Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" Section 8.4 of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (April 1 from October 1, 2013 to March 31) , 2014 and the following fiscal years ending March 31. Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Designation/Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (from April 1 to March 31) 1, 2012. Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (April 1 to March 31) from July 19, 2013. Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Designation/Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.

Annual Reporting Template. The following document is the template that must be used for the submission of your Facility's Annual Report. The information requested in the template below pertains only to the insured Services provided in your Facility under contract with AHS for each fiscal year (from April 1 to March 31) 1, 20 . Name of Facility: Facility Address: Surgical Specialty Number of procedures performed [year], by category Enhanced Medical Goods & Services Please provide a list and statement of revenues for all enhanced medical goods and services provided by your Facility. Annual Reporting Template (Continued) List ALL Staff (related to delivery of insured Services with AHS). Please insert date of issue and re-certification for BCLS/ACLS/PALS. Provide photocopies of updated BCLS/ACLS/PALS certifications and proof of professional registration. *PALS only required if children under ten (10) years of age require recovery room care (as required in Schedule D). Last Name First Name Professional Designation/ Title BCLS Issued BCLS Update ACLS Issued ACLS Update *PALS Issued *PALS Update "Schedule D" of the Agreement states that Medical Staff working in the surgical Facility must have Medical Staff privileges with AHS. Please provide a list of all physicians working in your Facility. Please list your Medical Staff Director first. Medical Staff Director Last Name: Medical Staff Director First Name: Physician Last Names: Physician First Names: Article 10 of the Agreement describes the requirement for teaching and research activities at your Facility. Summarize your Facility's teaching and/or research activity. Annual Reporting Template (Continued) Schedule “D” of the Agreement requests a summary of your Facility's quality assurance and monitoring activities. Summarize your Facility's quality assurance activity.