AMD Center of Excellence Application

Please fill out the application in full.

Membership Requirements

  • Completion and submission of this enrollment application.

  • Application fee of $300.00 is due with receipt of this application form. Please make your check payable to the “Macular Degeneration Association”.

  • Facility must operate business in compliance with all applicable federal and state licensure and regulatory requirements for the health and safety of patients.

  • All physicians treating age-related macular degeneration (AMD) should be fellowship trained in retina, board certified in ophthalmology and members in good standing of both American Society of Retina Specialists (ASRS) and American Academy of Ophthalmology (AAO).

  • The physical facility must contain space for equipment appropriate to the services designated on the enrollment application, facilities for hand washing, adequate patient privacy accommodations and the storage of both business records and current medical records.

  • Facility should have all applicable diagnostic testing equipment available at the physical site such as a spectral domain or swept source OCT device, fundus photography, autofluorescence, fluorescein angiogram and diagnostic testing equipment.

Testing equipment must be calibrated and maintained per equipment instructions and in compliance with applicable manufacturers suggested maintenance and calibration standards.

A current complete catalog of diagnostic equipment, including diagnostic testing equipment serial and registration numbers, must be maintained at the physical site and available to the Macular Degeneration Association upon request.

  • Each physician/facility should meet at least one of the following conditions:

 At a minimum, at least 30% of your practice should be AMD patients

 Participate in a multicenter study investigating a new treatment for AMD

 Lecture on AMD

 Author of a paper or publication on AMD

  • All physicians must stay current on all new technology while offering FDA approved new services to their patients. All doctors agree to have available the following medications: Avastin, Lucentis, Eylea and any new anti-VEGF/similar medication approved by the FDA and Medicare.

 

  • Have technical staff on duty with the appropriate credentials to perform diagnostic tests. The physical facility must be able to produce the applicable federal or state licenses or certifications of the individuals performing these services.

  • Maintain primary business phone under the name of the designated business. The primary business phone must be located at the designated site of the business. The telephone number or toll-free numbers must be available in a local directory and through directory assistance.

  • Maintain a physical facility on an appropriate site. For the purposes of this standard, a post office box, commercial mail box, hotel or motel is not considered an appropriate site.

  • The AMD Center of Excellence plaque must be visible during business hours and a posted picture on the physicians’ website.

Important Notes

  • Applicant must provide complete and accurate information on the enrollment application.

  • Changes in ownership, location, general supervision, adverse legal actions and all other changes to the enrollment application must be reported within 90 calendar days to the Macular DegenerationAssociation.

 

  • Submit facility photos and logo (Provide the facility logo in PNG format and a minimum 300 kb).

  • All applications and submitted documentation will be reviewed by the Macular Degeneration Association’s Medical Director for final approval as an AMD Center of Excellence.
On