NUCCA Application for Accreditation

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While completing your application you have the option to save your progress and get emailed a link to continue at a later time.

If you have any questions while completing your application, contact Cari Withrow, Accreditation Coordinator, at 407-521-5789 or cwithrow@ucaccreditation.org.

Let's get started on your application for accreditation!

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Legal Name of Practice* This field is required.If the center has a “dba” or is known to the public or patients by a different name than the legal name, indicate the dba on the next page.

Legal Name of Practice

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"DBA"If the center has a “dba” or is known to the public or patients by a different name than the legal name, indicate the dba here. If none, skip this page.

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Medical Director* This field is required.

First Name

Last Name

MD/DO

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If the clinic is not-yet operational, indicate the anticipated date services will begin (month/year). If N/A, skip to the next page.An Urgent Care Center may apply for accreditation up to eight months before the clinic becomes operational

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If the clinic is not-yet operational are you applying for the Early Survey Program? If N/A, skip to the next page.(see the brochure and/or the NUCCA Handbook for Urgent Care Center Accreditation for more information about the Early Survey Program)

YESNO

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Practice Administrator/Manager* This field is required.

First Name

Last Name

Suffix

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Address* This field is required.If this is an Urgent Care group with multiple clinic locations, enter the corporate address or the address of the main clinic site (if there is no corporate address)

Street Address

Street Address Line 2

City

State

Zip Code

Country

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Phone Number* This field is required.

Please enter a phone number.

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Fax Number* This field is required.

Please enter a fax number.

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Web Address* This field is required.

Web Address

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Accreditation Contact * This field is required.This is the person who is the point of contact for the Accreditation Coordinator who will serve as the liaison for the clinic(s) for all accreditation matters, including scheduling reviews, etc.

First Name

Last Name

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Accreditation Contact Phone Number* This field is required.

Please enter a valid phone number.

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Accreditation Contact Email Address* This field is required.

example@example.com

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Indicate which of the following best describes your facility type* This field is required.

Urgent Care Center

Community Health Center

Occupational Health Center

Student Health Center

Hospital-Based Fast-Track/Urgent Care

Other

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Main Site* This field is required.If this is an Urgent Care group with multiple clinic locations, provide the information of the main clinic site. You will have the opportunity on the next page to add additional locations.

Name of Main Site

Address of Main Site

Phone Number of Main Site

Number of providers at this location

Date this location opened (month/year)

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Additional Clinic LocationsIf this is an Urgent Care group with multiple clinic locations, upload a file providing the clinic name, address, phone number, number of providers and date opened (mon/year) of each locations. File format may be doc, docx, xls, xlsx, csv or zip.

Drag and drop files here

Select files to upload

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List, by specialty: the number of full-time providers, the number of part-time providers, and the number of full-time equivalents (FTEs) of part-time providers who are engaged in providing services across all clinic locations.* This field is required.

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Medicare Provider Number* This field is required.

Medicare Provider Number

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Are there other Medicare Certifications?* This field is required.(If Yes, provide information on the next page)

YESNO

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If you answered 'Yes' to the previous question, provide information here. If 'No', skip to the next page.

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Tax ID* This field is required.

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Are diagnostic imaging services provided?* This field is required.

YESNO

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If you answered 'Yes' to providing diagnostic imaging services, indicate which services are provided:(If you answered 'No', skip to the next page)

X-ray

CT

MRI

Other

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Does the center provide occupational health services on a regular basis for employees, employers and workers' compensation carriers?* This field is required.

YESNO

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Has your center been ever previously accredited?* This field is required.

YESNO

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If your center has previously been accredited, provide the name of the accrediting organization.(If you answered 'No', skip to the next page)

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1. Is there any physician/practitioner in your center whose license has been suspended, revoked or voluntarily surrendered?* This field is required.

YESNO

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2. Is there any physician/practitioner in your center whose license is currently under review by the state medical board?* This field is required.

YESNO

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3. Has your center placed any limitations or conditions on any practitioner's privileges?* This field is required.

YESNO

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4. Are there any litigation/malpractice cases currently pending within the past five years against the center and/or a physician/practitioner?

YESNO

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5. Has the center had any unfair labor practice filings or any other litigation involving the center or its officers?* This field is required.

YESNO

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Provide complete details for any 'Yes' responses to questions 1 - 5If all answers are 'No', skip to the next page

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How did you first learn about National Urgent Care Center Accreditation?* This field is required.

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How long has your center been considering accreditation?* This field is required.

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What factors contributed to your desire to accredit your Urgent Care Center(s)* This field is required.Select all that apply

To reduce malpractice rates

To potentially increase reimbursement by health insurance carriers, or other third-party payors

To maintain or obtain HMO/managed care contracts

To communicate and market your facility’s standard of quality to the public

To obtain educational and consultative guidance

To meet state (or federal) legislative/regulatory requirements

To obtain Medicare certification

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Be sure to read this information completely, then sign your application on the next page.

This Application is governed by and shall be construed in accordance with the laws of the State of Florida. NUCCA shall at all times be an independent contractor as to Applicant, and shall exercise objectivity in making all Accreditation determinations. In no event will NUCCA's aggregate liability arising out of or related to this Application exceed the Application Fee paid by Applicant.

All written or verbal information provided to National Urgent Care Center Accreditation (“NUCCA”) by Applicant regarding this Application, the survey and/or Accreditation process must be accurate, complete, and true. Applicant is subject to the current Accreditation policies and procedures of NUCCA. As an Accredited Center, the Applicant will receive notice regarding changes in NUCCA policies and procedures.

The Applicant agrees to hold NUCCA and its members, officers, directors, governors, examiners, and agents, free and harmless from any damage, expense, complaint, or cause of action whatsoever by reason of any action they, or any of them, may reasonably take in connection with this Application, the investigation of same, the failure of NUCCA to admit the Applicant to the Accreditation process. NUCCA makes no warranties, representations, or guarantees as to Applicant’s ability to obtain Accreditation.

NUCCA will maintain as confidential all information provided and will not disclose such information to any third party except on prior written authorization from the Applicant. If NUCCA and/ or its affiliates or representatives becomes legally compelled by law, process or order of any court or governmental agency or otherwise to disclose Confidential Information, or legal counsel therefore opines in writing that NUCCA or its affiliates or representatives is required to disclose any Confidential Information, NUCCA shall be relieved of its confidentiality obligations under this Section solely as and to the extent that it becomes legally compelled to disclose Confidential Information. As used herein “Confidential Information” shall include (i) all analyses, compilations, studies or other documents prepared by NUCCA or its representatives containing or based in whole or in part on any confidential information furnished by the Applicant, and (ii) all work product of any kind produced by NUCCA or its affiliates in the course of or in connection with the Accreditation.

Applicant agrees that the terms and conditions stated in this Application shall govern the relationship between Applicant and NUCCA, including this Accreditation, any additional locations seeking future accreditation, and renewal of Accreditation.

On behalf of the Applicant, the undersigned certifies that all information submitted is complete and accurate as of the date below. Applicant will notify NUCCA if there are any changes to this information. Applicant understands that the Accreditation application fees are due prior to NUCCA’s on-site survey, and that all fees should be paid to NUCCA. Applicant understands that in addition to the application fee, Applicant is responsible for all travel expenses for the surveyor (for example: airfare, hotel, car rental, meals, etc.) which will be invoiced to the clinic after the completion of the on-site review(s).

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Medical Director SignatureI have read and understand the information regarding my application for accreditation

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Accreditation Fees

1 clinic: $2,500

2 or more clinics: $2,500 for the first location + $500 per location for each additional location

For groups with 50 or more clinic locations, the price per location for 51 or more locations is $450 per location.

For groups with 100 or more clinic locations, the price per location for 101 or more locations is $350 per location.

The application fee must accompany the accreditation application. You may enter credit card information on the next page, or, you may send the appication along with a check to:

National Urgent Care Center Accreditation

2813 S. Hiawassee Rd., Suite 206

Orlando FL 32835-6690

The clinic is also responsible for travel expenses for the surveyor (airfare, hotel, car rental and meals, as applicable) [to be invoiced to the clinic after completion of the on-site review(s)].

**Urgent Care Centers have 14 days from the date the application and application fee is received by National Urgent Care Center Accreditation (confirmation of receipt of payment is sent via email by Cari Withrow, Accreditation Coordinator, cwithrow@ucaccreditation.org) to request a refund of their application fee (less $250 processing fee to be retained by National Urgent Care Center Accreditation) if they elect not to seek accreditation. Notification of non-pursuit of accreditation and request for refund must be submitted in writing (via postal mail or email). After 14 days all fees are non-refundable.**

The on-site review will take place within six weeks from receipt of your application (depending on reviewer availability). The Accreditation Coordinator will coordinate with the clinic and the reviewer to schedule which locations will be reviewed and the dates of each review to ensure a smooth review process.

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Use this form to pay your accreditation fee. Upload the completed form on the next page. If paying by corporate check, skip the next page, submit your application and mail your payment to: National Urgent Care Center Accreditation, 2813 S. Hiawassee Rd., Suite 206, Orlando FL 32835.

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Upload the completed credit card form or, if paying by corporate check, submit your application and mail your payment to: National Urgent Care Center Accreditation, 2813 S. Hiawassee Rd., Suite 206, Orlando FL 32835.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB