COPE CE Administrator/Provider Application

HOT LINKS

COPE CE Organization Structure

The following section is intended to collect information about your organization's corporate structure. COPE needs to ensure your organization is not an ineligible company (i.e. any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. Providers of clinical service directly to patients are not considered to be an ineligible company.)

Some organizations are automatically exempt from COPE's definition of an ineligible company, including government organizations, non-health care related companies, liability insurance providers, health insurance providers, group optometric practices, for-profit hospitals, for-profit rehabilitation centers, for-profit nursing homes, blood banks, and diagnostic laboratories that do not sell proprietary products. NOTE: 501c organizations are screened for eligibility. Those that advocate for ineligible companies as a 501c organization are not eligible to become COPE Approved Administrators/Providers.

Select a response if any of the following exemptions is applicable to your organization.

You must submit an answer for either number 1 or number 2.

1. My organization is exempt from COPE's definition of an ineligible company because it is a:

2. My organization is not exempt from COPE's definition of an ineligible company. (You must answer all of the following questions so that COPE can assess your organization's eligibility.)

A. Does your organization produce, market, resell, or distribute health care goods or services consumed by or used on patients?

Yes No

Explanation

B. Is your organization owned or controlled by an entity that produces, markets, resells, or distributes health care goods or services consumed by, or used on patients?

Yes No

Explanation

C. Is there anywhere within the larger corporate structure of your organization an entity that produces, markets, resells or distributes health care goods or services consumed by or used on patients?

Yes No

D. If you answered YES to item C above, please specify the organizational and procedural relationship of the ineligible company to your organization.

Explanation

E. Are there organizational and procedural safeguards (corporate firewalls) in place to ensure that the CE entity is separate from any ineligible company listed in item d above?

Yes No

F. If you answered yes to item e above, describe and attach an organizational chart to depict the organizational and procedural safeguards in place to ensure that the CE entity is separate from any ineligible company within the larger corporate structure of your organization.

Description

Organizational Chart:

Additional Comments

COPE CE Organization Contacts

Primary Contact First Name:*

Primary Contact Last Name:*

Primary Contact Title:*

Primary Contact Phone:*

Primary Contact E-Mail:*

Primary Contact Fax:

Other Contact First Name:

Other Contact Last Name:

Other Contact Title:

Other Contact Phone:

Other Contact E-Mail:

Other Contact Fax:

Other Contact First Name:

Other Contact Last Name:

Other Contact Title:

Other Contact Phone:

Other Contact E-Mail:

Other Contact Fax:

Other Contact First Name:

Other Contact Last Name:

Other Contact Title:

Other Contact Phone:

Other Contact E-Mail:

Other Contact Fax:

COPE CE Organization Commitment

Before your organization can be accepted as a COPE Approved Administrator/Provider, your understanding a commitment to abide by COPE's standards must be confirmed.

By checking this box, my organization acknowledges that we have read and understand all of COPE's rules

By checking this box, my organization agrees to adhere to all of COPE's rules in all aspects of our CE activities

HOT LINKS

COPE CE Organization Information

COPE CE Organization Structure

Select a response if any of the following exemptions is applicable to your organization.

You must submit an answer for either number 1 or number 2.

COPE CE Organization Contacts

COPE CE Organization Commitment

Warning!

Success!