application for certification adult echocardiography (ascexam) · certification adult...
TRANSCRIPT
Application for Certification
Adult Echocardiography (ASCeXAM)
Certification Requirements and Application
• •
National Board of Echocardiography, Inc.® 1500 Sunday Drive, Suite 102 • Raleigh, NC 27607
Phone: 919-861-5582 • Email: [email protected] Website: www.echoboards.org
2
THIS PAGE INTENTIONALLY LEFT BLANK
3
Contents
General Information Introduction .........................................................................................................................................................................................................................4
Eligibility ..............................................................................................................................................................................................................................4
Certification ApplyingforCertification ..............................................................................................................................................................................................5-6
BoardCertificationRequirements ...............................................................................................................................................................................7-11
Special Circumstances ....................................................................................................................................................................................................................12
CertificationInstructions.................................................................................................................................................................................................13
ApplicationforConversionfromTestamurtoCertifiedStatus .......................................................................................................................... 15-16
ApplicationforChangeinCertificationStatus ............................................................................................................................................................17
ChecklistsChecklistforCertificationin:Comprehensive(c),Transthoracic(t),Transthoracicplus Transesophageal(te),andTransthoracicplusStress(ts)Echocardiography, ASCeXAMwithCertification,andConversionfromTestamurtoCertifiedStatus ............................................................................................. 18
ChecklistforCertificationin:TransesophagealEchocardiography(e)for Cardiovascular Anesthesiologist or Cardiovascular Surgeon (ASCeXAMandConversionfromTestamurtoCertifiedStatus) ............................................................................................................................19
ChecklistforChangeinCertification ............................................................................................................................................................................20
Sample Letters For Physicians Less Than 3 years out of Training ......................................................................................................................................................21
For Physicians Who Completed Fellowship prior to July 1, 2009, and are in Private Practice ............................................................................ 22
For Physicians Who Completed Fellowship prior to July 1, 2009, and Work in a Hospital Setting .................................................................... 23
Please check our website at www.echoboards.org for future application deadlines.
4
Introduction
National Board of Echocardiography, Inc.TheNationalBoardof Echocardiography,Inc.(NBE)wasformedinDecember1998.TheNBEisanot-for-profitcorporationestablishedto:
• Developandadministerexaminationsinthefieldof ClinicalEchocardiography,
• Recognizethosephysicianswhosuccessfullycompleteeithertheexaminationof SpecialCompetenceinAdultEchocardiography(ASCeX-AM)orthePerioperativeTransesophagealEchocardiographyexamination(PTE),and
• Developacertificationprocessthatwillpubliclyrecognizethosephysicianswhohavecompletedanapprovedtrainingprograminechocar-diographyasspecifiedinthisapplicationandhaveadditionallypassedtheASCeXAM.
Theexaminationandcertificationof SpecialCompetenceinEchocardiographyarenotintendedtorestrictthepracticeof echocardiography.The process is undertaken, rather, in the belief that the public desires an indication from the profession regarding those who have made the ef-fort to optimize their skill in the performance and interpretation of cardiac ultrasound.
Thefirstexaminationinclinicalechocardiographywasgivenundertheauspicesof theAmericanSocietyof Echocardiography(ASE)asafieldtest in 1995. An examination of special competence was given in 1996, again under the ASE, and in 1997 and 1998 under ASCeXAM, Inc. Since 1999 the exam has been administered annually by the NBE. For these examinations, the title of “Testamur” was designated for successfully passingtheexamination.Thisdesignationwaschosensinceapplicantswerenotrequestedtosupplyinformationregardingsuccessfulcomple-tion of training dedicated to the study of Cardiovascular Disease nor completion of special training in echocardiography. With a mature and well-testedexamination,awell-definedbodyof knowledge,publishedtrainingguidelines,andpublishedcontinuingqualityimprovementguide-linestheNBEbeganofferingcertificationin2001.
Eligibility
CertificationLicensedphysicianswhomeetthecriteriaforcertificationmayapplyforCertificationatthetimeof applicationfortheASCeXAM.Theappli-cation,checklist,andallrequireddocumentationshouldbesubmittedwiththeapplication.TheCertificationCommitteewillmeettoreviewapplicationsforcertification.Applicantswillbenotifiedinwritingof thedecisionof theCommittee.Reviewof applicationforcertificationwillbecontingent on successful completion of the ASCeXAM. Applicants will receivenotificationof thedecisionof thecommitteewithintheyear.
Individuals who pass the ASCeXAM and who have completed Cardio-vascularDiseaseandechocardiographytrainingrequirementsbyJune30,2009mayapplyforcertificationatanypointinwhichtheymeettheclini-calexperiencerequirementsaslongastheirTestamurstatusremainsvalid.
For individuals who completed training after June 30, 2009 and failed to meettherequirementsforcertificationduringfellowshiptraining,they
canonlyqualifyforcertificationbyobtainingadditionaltraininginanACGME accredited or other nationally accredited training program.
Please refer to page 10 for additional information.
Testamur StatusForlicensedphysiciansnotmeetingthecriteriaforcertification,theNBEwill continue to allow access to the examination. This is to encourage physicians to test and demonstrate their knowledge of echocardiography based on an objective standard and to allow the medical community the opportunity to recognize individuals who elect to participate in and suc-cessfully complete a comprehensive examination in echocardiography. Thosewhosuccessfullypasstheexamination,butdonotfulfilltheneces-sarycriteriaforcertification,willcontinuetobedesignatedas“Testamur”of the National Board of Echocardiography.
4
Policy NoticeDefinitionof Interpretation:
Interpretation by a Trainee is defined to be independent reading and reporting of an echocardiographic study followed by review with, or under the direct supervi-sion of, an attending physician. Studies read by an attending with the trainee as an observer are not to be counted.
Whilethishasalwaysbeentheintentionof theNBE,thisstrictdefinitionwillbeappliedtofellowswhobegintheirtrainingonorafterJuly1,2010.
5
Applying for Certification
Who May Apply?Licensedphysicianswhomeetthecriteriamayapplyforcertificationatthe time of application for the ASCeXAM. The application, checklist, and allrequireddocumentationshouldbesubmittedwiththeapplication.TheCertificationCommitteewillmeettoreviewapplicationsandapplicantswillbenotifiedinwritingof thedecisionof thecommittee.Reviewof applicationforcertificationwillbecontingentonsuccessfulcompletionof theASCeXAM.Applicantswillreceivenotificationof thedecisionof the committee within 12 months.
The Purposes of the Certification Process are to:• establish the domain of the practice of echocardiography for the
purposeof certification,
• assess the level of knowledge demonstrated by a licensed physician practitioner of echocardiography in a valid manner,
• enhancethequalityof echocardiographyandindividualprofessionalgrowth in echocardiography,
• formallyrecognizeindividualswhosatisfytherequirementssetbytheNBE, and
• servethepublicbyencouragingqualitypatientcareinthepracticeof echocardiography.
Levels of Certification offered:• Transthoracic 2-D and Doppler Echocardiography
interpretation alone (t)
• Transesophageal Echocardiography (e)
• Transthoracic plus Transesophageal Echocardiography (te)
• Transthoracic plus Stress Echocardiography (ts)
• Comprehensive (c) which includes all three procedures
PhysicianswhohavebeencertifiedinTransthoracicEchocar-diography(orhigher)bytheNBEandcompletedcardiovasculardisease training prior to July 1, 2009 may apply for additional certificationoncetheirlevelof serviceinthoseareasmeetstheminimumrequirements.(SeePage18)
PhysicianswhohavebeencertifiedinTransthoracicEchocar-diography(orhigher)bytheNBEandcompletedcardiovasculardisease training between July 1, 2008 and June 30, 2009 must wait three years from the end of fellowship program to apply for an additionalcertificationlevel(i.e.addingstressand/ortransesopha-gealechocardiographycertification)underthepracticeexperiencepathway or they must obtain additional training in an ACGME accredited or other nationally accredited fellowship program.
PhysicianswhohavebeencertifiedinTransthoracicEchocardiog-raphy(orhigher)andcompletedcardiovasculardiseasetrainingafterJune30,2009areonlyeligibletoapplyforadditionalcertifi-cation(i.e.addingstressand/ortransesophagealechocardiographycertification)byobtainingadditionaltraininginanACGMEac-credited or other nationally accredited fellowship program.
Please refer to page 10 for additional information.
6
Applying for Certification
Certification Documentation and InstructionsThe National Board of Echocardiography, Inc. reserves the right to audit stated clinical experience and continued provision of services in echocar-diographyforthesakeof eligibilityforcertification.
Letters Documenting Training and/or Level of Service:
All letters documenting training and/or level of service MUST be on appropriate letterhead, MUST be notarized, MUST contain EXACT numbers of studies performed and interpreted, and MUST be the original letter (no copies accepted). Applications with letters not meeting these criteria will not be reviewed. Sample letters are available on pages 21-23 and on our Web site: www.echoboards.org.
Lettersdocumentingtrainingand/orlevelof servicefromDivisionorDepartment Head of Cardiovascular Disease, the Fellowship Training Di-rector, Director of Cardiovascular Anesthesiology, the Training Director, ortheMedicalDirector*of theEchocardiographyLaboratory(LevelIII)MUST be on appropriate letterhead and MUST be notarized.
For applicants who completed their fellowship after July 1, 2009 a state-ment from the Training Director must be included that indicates that the applicanthastheclinicalcompetenceandprofessionalqualitiesnecessaryto perform as an independent echocardiographer. In the absence of a formal director of the echocardiography laboratory, the letter should be written by an appropriate supervising physician.
*Note: If applicant is the Medical Director of the Echocardiography Laboratory, the letter should be from the Chief of Cardiology or the Chief of Staff of the Hospital.
If applicantsareinprivatepracticeandservicesareprovidedintheoffice,the letter documenting level of service must be on appropriate letterhead and should be written by the CEO or President of the practice. If the applicant is the CEO or President of the practice, the letter should be written by the business manager.
For the purpose of Certification, a study performed and/or in-terpreted may be counted only once and must be counted under the code that it was billed. Example: Even though a full TTE is performed as part of a Stress Echo with only a single bill being submitted (93350), the study must be counted as a Stress Echo and cannot be counted as both a TTE and a Stress.
Werequestthatthenotarizedlettersverifyingthenumberof studiesperyear for the appropriate time, 2 or 3 years broken down by procedure code in the following format.
Yr.1(2012) Yr.2(2013) Yr.3(2014)
Transthoracic(93303-93308) ### ### ###
Transesophageal(93312-93317) ### ### ###
StressEcho(93350) ### ### ###
NOTE: The numbers provided must be in parallel, consecutive years but need not be calendar years. The end of the most recent year for which credit is requested must fall within the 12 months prior to receipt of the complete application.
The EXACT number of studies performed and interpreted per year MUSTbeprovided.Applicationscontainingapproximatedand/orround-ednumberswillnolongerbereviewedbytheCertificationCommittee.
Review of Documentation for CertificationSinceCertificationisdependentonpassingtheASCeXAM,applicationsforCertificationarereviewedaftertheexaminationhasbeensatisfactorilycompleted.
Effective Date of CertificationCertificationwillberetroactivetothedatethattheSpecialCompetencyExam(ASEeXAMorASCeXAM)waspassedandbevalidforten(10)yearsfromthatdate,e.g.if theexamwaspassedin1999certificationwillbevaliduntilJune30,2009.If theexamispassedin2015,certificationwill be valid until June 30, 2025.
Change in Certification PolicyThischangeinCertificationPolicyaffectsallfellowswhowillcom-plete their training after June30, 2009 (i.e. thosewhobegan theirtrainingonorafterJuly1,2006).Specifically,fellowscompletingtheirfellowshipafterJune30,2009canONLYqualifyforcertificationbycompletinglevelIItraininginechocardiography(6monthsof formaltraining in echocardiography)during their fellowship including thesatisfactory performance of at least 150 transthoracic echocardiograms and the interpreting of at least 300 transthoracic studies. Additional certification in stress echocardiography requires the performanceand interpretation of at least 100 stress echocardiograms while ad-ditional certification in transesophageal echocardiography requiresthe performance of at least 50 transesophageal echocardiograms. Individuals who fail to satisfy these requirements during their fellowship can only qualify for certification by obtaining addi-tional training in an ACGME accredited or other nationally ac-credited fellowship program. For this group, practice experience will no longer be accepted as an alternative to formal training.
Please refer to page 10 for additional information.
Policy NoticeDefinitionof Interpretation:
Interpretation by a Trainee is defined to be independent reading and reporting of an echocardiographic study followed by review with, or under the direct supervision of, an attending physician. Studies read by an attending with the trainee as an observer are not to be counted.
While this has always been the intention of the NBE, this strict definitionwillbeappliedtofellowswhobegintheirtrainingonorafter July 1, 2010.
7
Board Certification Requirements
BOARD CERTIFICATION REQUIREMENTS 1-4 REQUIRED DOCUMENTATION
Certification Levels• Comprehensive Certification (c) – Includes all Three - Transthoracic, Transesophageal, and Stress Echocardiography
• Transthoracic Certification (t) – Transthoracic (Cardiovascular Clinician)
• Transesophageal Echocardiography (te) - Transthoracic Plus Transesophageal Echocardiography (Cardiovascular Clinician) (e) - Transesophageal Echocardiography Alone (Cardiovascular Anesthesiologist, Cardiovascular Surgeon)
• Transthoracic Plus Stress Echocardiography Certification (ts)
What are the Six Requirements?Requirements 1-4andSupportingDocumentationwhicharethesameforalllevelsof certificationarelistedbelow.
Requirement 5,seetheCardiovascularDiseaseTrainingTimeTablespecifictoyourclinicaltraining.
Requirement 6, the Application Fee.
Requirement 1. Testamur of the ASCeXAM
Requirement 2. Certification Eligibility License RequirementsApplicantswhowishtoapplyforcertificationmustholdavalid,unre-strictedlicensetopracticemedicineatthetimeof application.(Geo-graphicalrestrictionsmaybeacceptedandaresubjecttoapproval.)Medi-cal restrictions or restrictions to scope of practice will not be accepted for purposesof eligibilityforcertification.
Requirement 3. Current Medical Board CertificationApplicantsmustbeboardcertifiedbyaboardwhichholdsmembershipin the American Board of Internal Medicine, the Advisory Board for Os-teopathic Specialties, the American Association of Physician Special¬ists, or Royal College of Physicians and Surgeons of Canada.
Requirement 4. Specific Training in Cardiovascular DiseaseApplicants must have a minimum of 24 months of specialized clinical training dedicated to the study of Cardiovascular Disease. This training is to be at the fellowship level. Fellowship training in Cardiovascular Disease must be obtained at an ACGME accredited training program or other nationally accredited cardiovascular training program. That is, cardio-vascular rotations during general internal medicine, surgery, radiology, anesthesiology, or other general residencies can not be counted towards thisrequirement.MonthsspentinCardiovascularResearchmaynotbecountedtowardthisrequirement.
Requirement 1.Provide Year ASCeXAM Passed
If applyingforCertificationandExam,provideyearyou’retakingtheexam.
Requirement 2. (Oneof thefollowing):• Copyof Currentmedicallicenserenewalcertificatethatshowsan
expiration date;
• Copyof equivalentdocumentationof permissiontopracticemedicinein the country of principal residence.
Requirement 3.Copyof certificateof highestBoardCertificationattained,e.g.InternalMedicine,CardiovascularDisease,Anesthesiology,etc.(Acopyof ABIMCertificationinCardiovascularDiseaseispreferred.)
Requirement 4. (Oneof thefollowing):• Copyof acertificateof successfulcompletionof anaccreditedfel-
lowship in Cardiovascular Disease;
• An original notarized letter on appropriate letterhead from the Division or the Department Head of Cardiovascular Disease or Fellowship Training Director stating the applicant has successfully completed an approved Cardiovascular Disease Fellowship and the date of completion;
• An original notarized letter on appropriate letterhead from the hospital or appropriate departmental Training Director stating the applicant has completed a full 24 months of clinical training dedicated specificallytoCardiovascularDisease.Thelettermustdocumenttheinclusive dates of the training and the number of echoes performed and interpreted during training. A summary of the training program activitiesisrecommended.(SeeLettersDocumentingTrainingand/orLevelof Service:Page6)
8
BOAR
D CE
RTIF
ICAT
ION
REQU
IREM
ENT
5 –
CARD
IOVA
SCUL
AR D
ISEA
SE T
RAIN
ING
TIM
E TA
BLE
Sect
ion 1
Se
ction
2
Sect
ion 3
Le
vel o
f Cer
tifica
tion
Le
ss T
han
3 ye
ars
Traini
ng C
omple
ted
betw
een
Traini
ng C
omple
ted
prior
to
Ap
plied
For
: ou
t of T
raini
ng
July,
1, 1
990
& Ju
ly 1,
2009
Ju
ly 1,
1990
Board Certification Requirements
Com
preh
ensiv
e (c
)R
equi
rem
ent 5
. The
app
lican
t mus
t hav
e completedLevelIITraining(6monthstrain-
ing
with
per
form
ance
of
150,
and
inte
rpre
ta-
tion
of 3
00 tr
anst
hora
cic
echo
card
iogr
ams
and
perf
orm
ed a
nd in
terp
rete
d at
leas
t 50
tran
seso
phag
eal a
nd p
artic
ipat
ed in
and
in
terp
rete
d 10
0 st
ress
ech
ocar
diog
ram
s du
ring
training).
Supp
orti
ng D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d fr
om th
e Tr
aini
ng D
irect
or, o
r the
Med
ical
DirectoroftheEchocardiographyLab(Level
III),verifyingcompletionofLevelIITrain-
ing,
the
date
s of
trai
ning
, and
the
num
ber
of tr
anst
hora
cic,
tran
seso
phag
eal,
and
stre
ss
echo
es p
erfo
rmed
dur
ing
trai
ning
. The
lette
r m
ust i
nclu
de a
sta
tem
ent f
rom
the
Trai
ning
D
irect
or in
dica
ting
that
the
appl
ican
t “ha
s th
e clinicalcompetenceandprofessionalquali-
ties
nece
ssar
y to
per
form
as
an in
depe
nden
t ec
hoca
rdio
grap
her.”
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
completedLevelITraining(3monthstrain-
ing
with
per
form
ance
and
inte
rpre
tatio
n of
15
0 tr
anst
hora
cic
echo
card
iogr
ams
and
have
pr
ovid
ed e
choc
ardi
ogra
phy
serv
ices
of
at le
ast
4002-DimensionalEcho/Dopplerstudies,
50 tr
anse
soph
agea
l and
100
str
ess
echo
car-
diogramsperyearforeachoftwo(2)years
imm
edia
tely
pre
cedi
ng th
is a
pplic
atio
n.
Supp
orti
ng D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d verifyingthenumberof2-DEcho/Doppler
stud
ies,
tran
seso
phag
eal,
and
stre
ss e
choc
ar-
diog
ram
s pe
rfor
med
.
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
prov
ided
ech
ocar
diog
raph
y se
rvic
es o
f at
leas
t 4002-DimensionalEcho/Dopplerstudies
peryearforeachofthree(3)yearsimme-
diat
ely
prec
edin
g th
is a
pplic
atio
n. A
nd h
ave
perf
orm
ed a
nd in
terp
rete
d at
leas
t 50
tran
s-es
opha
geal
and
100
str
ess
echo
card
iogr
ams
peryearforeachoftwo(2)yearsimmediately
prec
edin
g th
is a
pplic
atio
n.
Supp
orti
ng D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d verifyingthenumberof2-DEcho/Doppler
stud
ies,
tran
seso
phag
eal,
and
stre
ss e
choc
ar-
diog
ram
s pe
rfor
med
.
Trans
thor
acic
Ce
rtific
ation
(t)
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
LevelIITraining(6monthstrainingwith
perf
orm
ance
of
150
and
inte
rpre
tatio
n of
300
transthoracicechocardiograms).
Supp
orti
ng D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d fr
om th
e Tr
aini
ng D
irect
or, o
r the
Med
i-ca
l Dire
ctor
of
the
Ech
ocar
diog
raph
y La
b (LevelIII)verifyingcompletionofLevelII
Trai
ning
, and
the
num
ber o
f tr
anst
hora
cic
stud
ies
perf
orm
ed d
urin
g tr
aini
ng. T
he le
tter
mus
t inc
lude
a s
tate
men
t fro
m th
e Tr
aini
ng
Dire
ctor
indi
catin
g th
at th
e ap
plic
ant h
as th
e clinicalandprofessionalqualitiesnecessary
to p
erfo
rm a
s an
inde
pend
ent e
choc
ardi
og-
raph
er.
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
completedLevelITraining(3monthstrain-
ing
with
per
form
ance
and
inte
rpre
tatio
n of
15
0 tr
anst
hora
cic
echo
card
iogr
ams
and
have
pr
ovid
ed e
choc
ardi
ogra
phy
serv
ice
of a
t lea
st
4002-DimensionalEcho/Dopplerstudiesper
yearforeachofthetwo(2)yearsimmediately
prec
edin
g th
is a
pplic
atio
n.
Supp
orti
ng D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d ve
ri-fyingthenumberof2-DimensionalEcho/
Dop
pler
stu
dies
per
form
ed p
er y
ear f
or e
ach
ofthetwo(2)yearsprecedingtheapplication.
Req
uire
men
t 5. T
he A
pplic
ant m
ust h
ave
prov
ided
ech
ocar
diog
raph
y se
rvic
es o
f at
leas
t 4002-DimensionalEcho/Dopplerstudies
per y
ear f
or e
ach
of th
ree
year
s pr
eced
ing
the
appl
icat
ion
Supp
orti
ng D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d ve
rifyi
ng th
e nu
mbe
r of
Tran
stho
raci
c st
udie
s performedperyearforeachofthree(3)years
prec
edin
g th
e ap
plic
atio
n.
IMP
OR
TA
NT
: If
you
com
plet
ed tr
aini
ng
afte
r Ju
ne 3
0, 2
009
and
you
faile
d to
mee
t the
re
quir
emen
ts fo
r ce
rti-
ficat
ion
duri
ng tr
aini
ng,
plea
se r
efer
to p
age
5 an
d pa
ge 1
0 fo
r ad
di-
tion
al in
form
atio
n.
Trans
esop
hage
al E
choc
ardio
grap
hy
(Inclu
des t
he
Follo
wing
Two)
:
Trans
thor
acic
and
Trans
esop
hage
al Ec
hoca
rdiog
raph
y Ce
rtific
ation
(te)
IMP
OR
TA
NT
: If
you
com
plet
ed tr
aini
ng
afte
r Ju
ne 3
0, 2
009
and
you
faile
d to
mee
t the
re
quir
emen
ts fo
r ce
rti-
ficat
ion
duri
ng tr
aini
ng,
plea
se r
efer
to p
age
5 an
d pa
ge 1
0 fo
r ad
di-
tion
al in
form
atio
n.
9
Board Certification Requirements
Trans
esop
hage
al E
choc
ardio
grap
hy
(Inclu
des t
he
Follo
wing
Two)
:
Trans
thor
acic
and
Trans
esop
hage
al Ec
hoca
rdiog
raph
y Ce
rtific
ation
(te)
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
completedLevelIITraining(6monthswith
the
perf
orm
ance
of
150,
inte
rpre
tatio
ns o
f 300transthoracicechocardiograms)andper
-fo
rmed
and
inte
rpre
ted
at le
ast 5
0 tr
anse
soph
-ag
eal e
choc
ardi
ogra
ms
durin
g tr
aini
ng.
Supp
orti
ng D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d fr
om
the
Trai
ning
Dire
ctor
, or t
he M
edic
al D
irect
or
oftheechocardiographylab(LevelIII),verify-
ing
the
com
plet
ion
of L
evel
II
Trai
ning
, the
da
te o
f tr
aini
ng, a
nd th
e nu
mbe
r of
tran
stho
-ra
cic
and
tran
seso
phag
eal s
tudi
es p
erfo
rmed
du
ring
trai
ning
. Thi
s le
tter m
ust i
nclu
de a
st
atem
ent f
rom
the
Trai
ning
Dire
ctor
indi
cat-
ing
that
the
appl
ican
t has
the
clin
ical
com
pe-
tenceandprofessionalqualitiesnecessaryto
perf
orm
as
an in
depe
nden
t ech
ocar
diog
raph
er.
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
completedLevelITraining(3monthstrain-
ing
with
per
form
ance
and
inte
rpre
tatio
n of
15
0 tr
anst
hora
cic
echo
card
iogr
ams
and
have
pr
ovid
ed e
choc
ardi
ogra
phy
of a
t lea
st 4
00
2-DimensionalEcho/Dopplerstudiesand50
tran
seso
phag
eal e
choc
ardi
ogra
ms
per y
ear f
or
each
of
two
year
s im
med
iate
ly p
rece
ding
this
ap
plic
atio
n.
Supp
orti
ng D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d ve
rifyi
ng th
e nu
mbe
r of
2-D
imen
sion
al
Echo/Dopplerstudiesandtransesophageal
echo
card
iogr
ams
perf
orm
ed.
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
prov
ided
ech
ocar
diog
raph
y se
rvic
es o
f at
leas
t 4002-DimensionalEcho/Dopplerstud-
iesperyearforeachofthethree(3)years
imm
edia
tely
pre
cedi
ng th
is a
pplic
atio
n an
d ha
ve p
erfo
rmed
and
inte
rpre
ted
at le
ast 5
0 tr
anse
soph
agea
l ech
ocar
diog
ram
s pe
r yea
r for
eachoftwo(2)yearsimmediatelypreceding
this
app
licat
ion.
Supp
orti
ng D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d ve
ri-fyingthenumberof2-DimensionalEcho/
Dop
pler
stu
dies
and
the
tran
seso
phag
eal
echo
card
iogr
ams
perf
orm
ed.
Trans
esop
hage
al
Echo
card
iogra
phy
Certi
ficat
ion (e
)
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
perf
orm
ed a
nd in
terp
rete
d at
leas
t 300
tran
s-es
opha
geal
ech
ocar
diog
ram
s w
ithin
a tr
aini
ng
prog
ram
.
Supp
orti
ng D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d fr
om th
e ho
spita
l or a
ppro
pria
te d
epar
tmen
tal
Trai
ning
Dire
ctor
, e.g
. Dire
ctor
of
Car
dio-
vasc
ular
Ane
sthe
siol
ogy,
stat
ing
the
appl
ican
t ha
s co
mpl
eted
a fu
ll 24
mon
ths
of c
linic
al
trainingdedicatedspecificallytoCardiovas
-cu
lar D
isea
se. T
his
lette
r mus
t doc
umen
t the
in
clus
ive
date
s of
the
trai
ning
and
the
num
ber
of tr
anse
soph
agea
l ech
oes
perf
orm
ed d
urin
g tr
aini
ng. A
sum
mar
y of
the
trai
ning
pro
gram
ac
tiviti
es is
reco
mm
ende
d.
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
perf
orm
ed a
nd in
terp
rete
d at
leas
t 150
tr
anse
soph
agea
l ech
ocar
diog
ram
s du
ring
the
trai
ning
pro
gram
and
per
form
ed a
t lea
st 1
00
tran
seso
phag
eal e
choc
ardi
ogra
ms
per y
ear f
or
eachoftwo(2)yearsimmediatelypreceding
appl
icat
ion.
Supp
orti
ng D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d fr
om th
e Tr
aini
ng D
irect
or o
r the
Med
ical
Di-
rect
or o
f Tr
anse
soph
agea
l stu
dies
per
form
ed
foreachofthetwo(2)yearsprecedingthis
appl
icat
ion.
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
perf
orm
ed a
t lea
st 1
00 tr
anse
soph
agea
l ech
o-cardiogramsperyearforeachofthethree(3)
year
s im
med
iate
ly p
rece
ding
app
licat
ion.
Supp
orti
ng D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d fr
om th
e Tr
aini
ng D
irect
or o
r the
Med
ical
DirectoroftheEchocardiographyLab(Level
III)verifyingthenumberofTransesophageal
stud
ies
perf
orm
ed fo
r eac
h of
the
thre
e ye
ars
prec
edin
g th
is a
pplic
atio
n.
Trans
thor
acic
Plus
St
ress
Ech
ocar
diogr
a-ph
y Cer
tifica
tion
(ts)
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
completedLevelIITraining(6monthstrain-
ing
with
per
form
ance
of
150,
inte
rpre
tatio
n of300transthoracicechocardiograms)and
part
icip
ated
in a
nd in
terp
rete
d at
leas
t 100
st
ress
ech
ocar
diog
ram
s du
ring
trai
ning
.
Req
uire
d D
ocum
enta
tion
: An
orig
inal
not
a-riz
ed le
tter o
n ap
prop
riate
lette
rhea
d fr
om th
e Tr
aini
ng D
irect
or o
r the
Med
ical
Dire
ctor
of
theEchocardiographyLab(LevelIII)verifying
com
plet
ion
of L
evel
II
Trai
ning
, the
dat
es
of tr
aini
ng, a
nd th
e nu
mbe
r of
tran
stho
raci
c an
d st
ress
ech
oes
perf
orm
ed d
urin
g tr
aini
ng.
The
lette
r mus
t inc
lude
a s
tate
men
t fro
m th
e Tr
aini
ng D
irect
or in
dica
ting
that
the
appl
ican
t ha
s th
e cl
inic
al c
ompe
tenc
e an
d pr
ofes
sion
al
qualitiesnecessarytoperformasanindepen-
dent
ech
ocar
diog
raph
er.
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
completedLevelITraining(3monthstrain-
ing
with
per
form
ance
and
inte
rpre
tatio
n of
15
0 tr
anst
hora
cic
echo
card
iogr
ams
and
have
pr
ovid
ed e
choc
ardi
ogra
phy
serv
ices
of
at
least4002-DimensionalEcho/Dopplerstud-
ies
and
100
stre
ss e
choc
ardi
ogra
ms
per y
ear
foreachoftwo(2)yearsimmediatelypreced-
ing
this
app
licat
ion.
Req
uire
d D
ocum
enta
tion
: An
orig
inal
no-
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d ve
rify-
ingthenumberof2-DimensionalEcho/
Dop
pler
stu
dies
and
str
ess
echo
card
iogr
ams
perf
orm
ed.
NO
TE
: The
num
bers
pro
vide
d m
ust b
e in
pa
ralle
l, co
nsec
utiv
e ye
ars
and
it is
not
lim
ited
to
cale
ndar
yea
rs.
Req
uire
men
t 5. T
he a
pplic
ant m
ust h
ave
prov
ided
ech
ocar
diog
raph
y se
rvic
es o
f at
leas
t 4002-DimensionalEcho/Dopplerstudies
peryearforeachofthree(3)yearsimme-
diat
ely
prec
edin
g th
is a
pplic
atio
n. A
nd h
ave
perf
orm
ed a
nd in
terp
rete
d at
leas
t 100
str
ess
echocardiogramsperyearforeachoftwo(2)
year
s im
med
iate
ly p
rece
ding
this
app
licat
ion.
Req
uire
d D
ocum
enta
tion
: An
orig
inal
no
tariz
ed le
tter o
n ap
prop
riate
lette
rhea
d ve
ri-fyingthenumberof2DimensionalEcho/
Dop
pler
stu
dies
and
str
ess
echo
card
iogr
ams
perf
orm
ed.
NO
TE
: The
num
bers
pro
vide
d m
ust b
e in
pa
ralle
l, co
nsec
utiv
e ye
ars
and
it is
not
lim
ited
to c
alen
dar y
ears
.
IMP
OR
TA
NT
: If
you
com
plet
ed tr
aini
ng
afte
r Ju
ne 3
0, 2
009
and
you
faile
d to
mee
t the
re
quir
emen
ts fo
r ce
rti-
ficat
ion
duri
ng tr
aini
ng,
plea
se r
efer
to p
age
5 an
d pa
ge 1
0 fo
r ad
di-
tion
al in
form
atio
n.
IMP
OR
TA
NT
: If
you
com
plet
ed tr
aini
ng
afte
r Ju
ne 3
0, 2
009
and
you
faile
d to
mee
t the
re
quir
emen
ts fo
r ce
rti-
ficat
ion
duri
ng tr
aini
ng,
plea
se r
efer
to p
age
5 an
d pa
ge 1
0 fo
r ad
di-
tion
al in
form
atio
n.
IMP
OR
TA
NT
: If
you
com
plet
ed tr
aini
ng
afte
r Ju
ne 3
0, 2
009
and
you
faile
d to
mee
t the
re
quir
emen
ts fo
r ce
rti-
ficat
ion
duri
ng tr
aini
ng,
plea
se r
efer
to p
age
5 an
d pa
ge 1
0 fo
r ad
di-
tion
al in
form
atio
n.
10
*For physicians less than 3 years out of training:Mustmake-upthedifferencetomeetLevelIItrainingrequirements
• Must have a minimum of 6-months in the echo lab
• MeetminimumnumbersforTTE(150,300)alongwithTEE(50)andStress(100),if desiredforcertification
IndividualswhofailtosatisfytheserequirementsduringtheirfellowshipcanonlyqualifyforcertificationbyobtainingadditionaltraininginanACGME accredited or other nationally accredited fellowship program.
(Pleasenotethatfor physicians completing their training on 6/30/2013 the number of years will be changed to NO ‘more than 4 yearstotaketheexaminationandapplyforcertification’andfor physi-cians completing their training on 6/30/2014 it will be change to NO ‘morethan3yearstotaketheexaminationandapplyforcertification.’Itwill remain at NO ‘more than 3 years to take the examination and apply forcertification’movingbeyond2014.)
*For physicians more than 5 years out of training there are two pathways to certification:Pathway #1:a)MeetthenumbersneededforLevelII(i.e.completewhatyouweredeficientin)atafacilitywithanACGMEaccreditedcardiologyfellowship training program or other nationally accredited cardiovascular trainingprogram,b)meettheminimumpracticenumbersthe2yearspriortocompletingthedeficienttrainingnumbers,c)provideaminimumof 15-hoursAMAcategory-1echo-specificCME.TheCMEmustbeacquiredduringthesameyearsinwhichthenumbersareprovided.
Pathway #2:a)MeetthenumbersneededforLevelII(i.e.completewhatyouweredeficientin)atafacilitywithanACGMEaccreditedcardiologyfellowship training program or other nationally accredited cardiovascular trainingprogram,b)meettheminimumpracticenumbersthe2yearsaftercompletingthedeficienttrainingnumbers,c)provideaminimumof 15-hoursAMAcategory-1echo-specificCME.TheCMEmustbeacquiredduringthesameyearsinwhichthenumbersareprovided.
(Pleasenotethatfor physicians completing their training on 6/30/2013 the number of years will be changed to NO ‘more than 4 yearstotaketheexaminationandapplyforcertification’andfor physi-cians completing their training on 6/30/2014 it will be change to NO ‘morethan3yearstotaketheexaminationandapplyforcertification.’Itwill remain at NO ‘more than 3 years to take the examination and apply forcertification’movingbeyond2014.)
For physicians who complete training after June 30, 2009 and did meet Level II training requirements but wait more than 5 years to take the exam and apply for certification, they also must meet one of the ad-ditional supplemental practice requirements:Pathway #1:a)meettheminimumpracticenumbersthe2yearsprior toapplication,b)provideaminimumof 15-hourAMAcategory-1echo-specificCMEandtheseCMEmustbeacquiredduringthesameyearsinwhich the numbers are provided.
Pathway #2:a)meettheminimumpracticenumbersthe2yearsafter initialapplication,b)provideaminimumof 15-hourAMAcategory-1echo-specificCMEandtheseCMEmustbeacquiredduringthesameyears in which the numbers are provided.
(Pleasenotethatfor physicians completing their training on 6/30/2013 the number of years will be changed to NO ‘more than 4 yearstotaketheexaminationandapplyforcertification’andfor physi-cians completing their training on 6/30/2014 it will be change to NO ‘morethan3yearstotaketheexaminationandapplyforcertification.’Itwill remain at NO ‘more than 3 years to take the examination and apply forcertification’movingbeyond2014.)
Requirements for Physicians that did not meet the required number of procedures during fellowship after June 30, 2009.
11
REQUIRED DOCUMENTATION
I. Additional Certification in Transesophageal EchocardiographyForthepurposeof Certification,astudyperformedand/orinterpretedmaybe counted only once and must be counted under the code that it was billed. Example: Even though a full TTE is performed as part of a Stress Echo withonlyasinglebillbeingsubmitted(93350),thestudymustbecountedas a Stress Echo and cannot be counted as both a TTE and a Stress.
Requirement 1.ApplicantsmustbecurrentlycertifiedbytheNBEinTransthoracicorTransthoracic Plus Stress Echocardiography, and cardiovascular disease training was completed prior to July 1, 2009.
Requirement 2.Applicants must show continued maintenance of skills in, transesopha-geal echocardiography according to the following:
Performance and interpretation of at least 50 transesophageal echocar-diogramsperyearforeachof thetwo(2)yearsimmediatelyprecedingthis application.
Requirement 3.ApplicationFee$50.00(USFunds)
Important: Please refer to the Policy Notice on page 5 for adding Additional Certification.
II. Additional Certification in Stress EchocardiographyForthepurposeof Certification,astudyperformedand/orinterpretedmaybe counted only once and must be counted under the code that it was billed. Example: Even though a full TTE is performed as part of a Stress Echo withonlyasinglebillbeingsubmitted(93350),thestudymustbecountedas a Stress Echo and cannot be counted as both a TTE and a Stress.
Requirement 1.ApplicantsmustbecurrentlycertifiedbytheNBEinTransthoracicorTransthoracic Plus Transesophageal Echocardiography, and cardiovascu-lar disease training was completed prior to July 1, 2009.
Requirement 2.Applicants must show continued maintenance of skills in, pharmacologic or exercise stress echocardiography according to the following:
Primary interpretation of at least 100 stress echocardiograms per year foreachof thetwo(2)yearsprecedingthisapplication.
Requirement 3.ApplicationFee$50.00(USFunds)
Important: Please refer to the Policy Notice on page 5 for adding Additional Certification.
Board Certification Requirements
See Application (page 17)
See Checklist (page 20)
An original notarized letter on appropriate letterhead from the Medical Directorof theEchocardiographyLaboratory(LevelIII)verifyingthenumber of transesophageal echocardiograms performed and interpreted peryearforeachof thetwo(2)yearsprecedingthisapplication.(SeeLet-tersDocumentingTrainingand/orLevelof Service:Page6)
Application fee may be paid by check, money order, Visa, or MasterCard in US Funds. The NBE does not accept American Express or Discover.
See Application (page 17)
See Checklist (page 20)
An original notarized letter on appropriate letterhead from the Medical Directorof theEchocardiographyLaboratory(LevelIII)verifyingthenumberof StressEchoesperformedperyearforeachof thetwo(2)yearsprecedingthisapplication.(SeeLettersDocumentingTrainingand/orLevelof Service:Page6)
Application fee may be paid by check, money order, Visa, or MasterCard in US Funds. The NBE does not accept American Express or Discover.
BOARD CERTIFICATION REQUIREMENTS
12
Special CircumstancesOther than 24 month Training in Cardiovascular Disease
The NBE recognizes that other albeit rare scenarios for obtaining 24 months of clinical training focused on Cardiovascular Disease are possi-ble.Applicantswhodonotmeetrequirement4forTransthoracicCertifica-tion(t)mayapplyforcertificationbyrequestingthatclinicalexperiencewithevidenceof stronginvolvementinCardiovascularDisease/Echo-cardiographybeacceptedforupto12monthsof therequirementforformal training.
These applications will be evaluated on a case-by-case basis for eligibility.
(PleasenotethatCardiovascularDiseasetrainingduringresidencycannotbeincludedaspartof this24monthrequirement.SeeRequirement4,page7.)
Requirements for consideration for certification with less than 24 months Cardiovascular Disease Training
Requirements 1, 2, 3, and 6 of Transthoracic (t) Certification and each of the following:
• Aletterrequestingthatclinicalexperiencewithevidenceof stronginvolvementinCardiovascularDisease/Echocardiographybeacceptedforupto12monthsof therequirementforformaltraining.
• A notarized letter on appropriate letterhead from the person respon-sible for the training, with detailed documentation of the training activities, statement of successful completion, and the inclusive dates must be supplied.
• Anotarizedletterdetailingnational/regionalmeetingsattended,paperspresented, lectures given, and peer reviewed publications in the realm of CardiovascularDiseaseand/orEchocardiographymustbesubmitted.
• A notarized letter on appropriate letterhead documenting the number of Transthoracic Echocardiograms performed per year in each of the precedingthree(3)years,andthenumberof TransesophagealEcho-cardiograms and Stress Echocardiograms performed per year in each of theprecedingtwo(2)years.(SeeLettersDocumentingTrainingand/orLevelof Service:Page6)
Requirement 1 for Transthoracic (t) Certification:
Testamur of the ASEeXAM or ReASCE.
Requirement 2 for Transthoracic (t) Certification:
Acurrentlicenseorequivalentdocumentationof permissiontopracticemedicine in the country of principal residence.
Requirement 3 Transthoracic (t) Certification:
Documentationof specialtyboardcertificationoritsequivalent.
Requirement 4 for Transthoracic (t) Certification:
Documentation of 24 months of training dedicated to Cardiovascular Disease.
Requirement 5 for Transthoracic (t) Certification:
Documentationof TrainingequivalenttoLevelII(seeabove)inthethree(3)yearspriortothisapplication(if trainingwascompletedsubsequenttoJuly1,1999),
OR
Documentationof TrainingequivalenttoLevelI(seeabove)andprovi-sionof thenumberof 2DEcho/Dopplerservicesperyearforeachof thetwo(2)yearspriortothisapplicationif trainingwascompletedbetween July 1, 1990 and July 1, 1999,
OR
Documentationof Provisionof thenumberof 2DEcho/Dopplerservicesperyearforeachof thethree(3)yearspriortothisapplicationif thetrainingin Cardiovascular Disease was completed prior to July 1, 1990.
OR
Documentation of Accreditation by The British Society of Echocardiography.
Requirement 6 for Transthoracic (t) Certification:
Application fee.
Non-North American Trained PhysiciansNon-NorthAmericantrainedphysiciansmusthavehadtheequivalent*of eachof theapplicabletrainingand/orclinicalexperiencerequirementstobeeligibleforcertification.
Applications will be reviewed on a case-by-case basis to determine the eligibilityof theapplicantforcertification.Documentationmustincludethe inclusive dates of training.
*Equivalentisdefinedassix(6)monthsof formaltraininginechocar-diographywithperformanceandinterpretationof atleast3002-DEcho/Doppler studies.
All documentation must be supplied in English. If original docu-mentation is not in English, a certified translation must be attached to each document.
Special Circumstances
Change in Certification PolicyThischangeinCertificationPolicyaffectsallfellowswhowillcom-plete their training after June30, 2009 (i.e. thosewhobegan theirtrainingonorafterJuly1,2006).Specifically,fellowscompletingtheirfellowshipafterJune30,2009canONLYqualifyforcertificationbycompletinglevelIItraininginechocardiography(6monthsof formaltraining in echocardiography)during their fellowship including thesatisfactory performance of at least 150 transthoracic echocardiograms and the interpreting of at least 300 transthoracic studies. Additional certification in stress echocardiography requires the performanceand interpretation of at least 100 stress echocardiograms while ad-ditional certification in transesophageal echocardiography requiresthe performance of at least 50 transesophageal echocardiograms. Individuals who fail to satisfy these requirements during their fellowship can only qualify for certification by obtaining addi-tional training in an ACGME accredited or other nationally ac-credited fellowship program. For this group, practice experience will no longer be accepted as an alternative to formal training.
Please refer to page 10 for additional information.
13
To Apply for Conversion from Testamur to Certified Status
1. Complete application on pages 15 and 16.
2. Sign the application on page 15. Unsigned applications will not be processed.
3. Complete the Check List on pages 18 or 19.
4. Includeallof therequireddocumentationforcertification.
5. If applicable, complete the section concerning method of payment. The NBE accepts check, money order, VISA, and Master Card. Make checks payable to National Board of Echocardiography, Inc. or NBE.
6. Submitapplication,alltherequireddocumentation,license,andfee(if applicable)toNBE.
To Apply for Change in Certification Status
1. Complete application on page 17.
2. Sign the application on page 17. Unsigned application will not be processed.
3. Complete the Check List on page 20.
4. Includeallof therequireddocumentationforcertification.
5. Complete the section concerning the method of payment. The NBE accepts check, money order, VISA, and MasterCard. Make checks payable to National Board of Echocardiography, Inc. or NBE.
6. Submitapplication,license,andfee(if applicable)toNBE.
NOTE: Cardiovascular disease training must have been completed prior to July 1, 2009.
IMPORTANT: Please refer to the Policy Notice on page 5 for addingAdditionalCertification.
Certification Application Instructions
14
THIS PAGE INTENTIONALLY LEFT BLANK
Please fill out the application carefully, accurately, and completely. Please print.
APPLICATIONS THAT ARE NOT SIGNED AND/OR DO NOT INCLUDE A COPY OF THE CURRENT MEDICAL LICENSE WILL NOT BE PROCESSED. (Medical license must show expiration date.)
Incomplete applications will not be reviewed by the Certification Committee. Faxed applications will not be accepted. Attach completed checklist (page 18 or 19) and all required documentation.
I am applying for (check one box): q Comprehensive Certification (Transthoracic, Transesophageal, and Stress) (c) q Transthoracic Certification (t) q Transthoracic plus Transesophageal Certification (te) – (Cardiovascular Clinician) q Transesophageal Certification (e) – (Cardiovascular Anesthesiologist or Cardiovascular Surgeon) q Transthoracic plus Stress Certification (ts)
Name ___________________________________________________________________________________________________________________ Last/Surname First(FullName) Middle(FullName)
Degree________________________SocialSecurityNumber(last4digits)_____________________________Dateof Birth ____________________
Mailing Address __________________________________________________________________________________________________________
City ____________________________________________ State _______ Zip________________ Country __________________________________
Address is (please check one): q Home q Business
TelephoneCountryCode*(OutsideUS&Canada) ___________________ TelephoneCityCode*(OutsideUSandCanada) _____________________
Business Telephone ___________________________________________ Cell Telephone _______________________________________________
Home Telephone _____________________________________________ E-mail(required) ______________________________________________
Application for Conversion from Testamur to Certified Status
**Did you include a copy of your current medical license that shows an expiration date
AND sign this application?**
Application Fee$175.00 (US Funds)
If you passed ASCeXAM in 1996-2001 ......................$175 (US Funds) If you passed ASCeXAM in 2002-2015 ............No Additional Charge
(included in exam fee)
Refund PolicyNo refunds will be made.
Payment Optionsq Check q Money Order q VISA q MasterCard
(The NBE Does Not Accept American Express or Discover)
Name on Card _____________________________________________
Card# __________________________________________________
Exp. Date ________________________________________________
Authorized Signature ________________________________________
I affirm that the information supplied in this application is true and correct.
The NBE reserves the right to request additional information/documentation on all applications.
Signature ________________________________________________ (Original signature required)
Unsigned applications will not be processed.Please answer the questions on the next page.
15
FO
R O
FF
ICE
USE
ON
LY
: __
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
__
____
____
____
____
____
____
_
LASTNAME
FIRSTNAME
MIDDLENAME
ID#
Mail, UPS, or FedEx completed application, check list, documenta-tion and payment to:
The National Board of Echocardiography, Inc. 1500 Sunday Drive, Suite 102 Raleigh, North Carolina 27607
Make checks payable to National Board of Echocardiography, Inc. or NBE.
FAXED APPLICATIONS WILL NOT BE ACCEPTED.
APPLICATIONS THAT ARE NOT SIGNED WILL NOT BE PROCESSED.
INCOMPLETE APPLICATIONS WILL NOT BE REVIEWED BY THE CERTIFICATION COMMITTEE.
To contact our office: Phone:(919)861-5582 E-mail: [email protected] Web site: www.echoboards.org
Note: It is the responsibility of the applicant to verify that all re-quired documentation is attached to the application. The applicant is also responsible for verifying that notarized letters are correct and in the required format.
Please check our website at www.echoboards.org for future application deadlines.
Application for Conversion from Testamur to Certified Status (continued)
16
Please circle the appropriate letter below:
1. I have been a practicing echocardiographer for ______ years.
A. 0-2 B. 3-5 C. 6-10 D. 11-15 E. 16-20 F. 20+
2. I spend the majority of my time in this discipline:
A. Anesthesiology
B. Internal Medicine
C. Radiology
D. Cardiology
E. PrimaryCare/FamilyMedicine
F. Pediatric Cardiology
G.Other(specify)_______________________________________
3. Type of Practice:
A. Private
B. HMO
C. Full-time Academic
D. Part-time Academic
E. Fellow
F. Other(specify)_______________________________________
4.Echocardiographicexaminationscurrentlyperformedand/or interpreted:
A. None
B. Less than 5 per week
C. 5-10 per week
D. 11-20 per week
E. Over 20 per week
5. Cardiovascular Disease Training:
A. Other than Formal Instruction (Attachbrief explanationandseerequirement4onchecklist)
B. FormalInstructionCardiovascularDiseaseTraining/Fellowship
Institution ___________________________________________
Director _____________________________________________
DateTrainingCompleted(mm/dd/yy) _____________________
6 Amount of Formal Echocardiography Training:
A. Less than 3 months
B. 3-6 months
C. Over 6 months
Institution ___________________________________________
Director _____________________________________________
DateTrainingCompleted(mm/dd/yy) _____________________
7. Iamrequesting12monthsasexperience. q Yes q No
(Idonothaveaminimumof 24monthsof trainingdedicatedtothestudyof cardiovasculardisease.)(SeePage11)
8. q I am North American Trained.
q I am Non-North American Trained.
NOTE: All documentation must be supplied in English. If original documentationisnotinEnglish,acertifiedtranslationmustbeattachedtoeachdocument.(SeePage12)
9. Iparticipated/passedtheExaminationof SpecialCompetencyinAdultEchocardiography(ASEeXAMorASCeXAM)in___________(Year).
17
Application for Change in Certification Status
Application Fee$50.00 (US Funds)
Refund PolicyNo refunds will be made.
Payment Optionsq Check q Money Order q VISA q MasterCard
(The NBE Does Not Accept American Express or Discover)
Name on Card _____________________________________________
Card# __________________________________________________
Exp. Date ________________________________________________
Authorized Signature ________________________________________
I affirm that the information supplied in this application is true and correct.
The NBE reserves the right to request additional information/documentation on all applications.
Signature ________________________________________________ (Original signature required)F
OR
OF
FIC
E U
SE O
NL
Y:
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
__
____
____
____
____
____
____
___
LASTNAME
FIRSTNAME
MIDDLENAME
ID#
Please fill out the application carefully, accurately, and completely. Please print.
APPLICATIONS THAT ARE NOT SIGNED AND/OR DO NOT INCLUDE A COPY OF THE CURRENT MEDICAL LICENSE WILL NOT BE PROCESSED. (Medical license must show expiration date.)
Incomplete applications will not be reviewed by the Certification Committee. Faxed applications will not be accepted. Attach completed checklist (page 20) and all required documentation.
I am currently certified in: (check one) q Transthoracic Echocardiography (t) q Transthoracic plus Transesophageal Echocardiography (te) – (Cardiovascular Clinician) q Transthoracic plus Stress Echocardiography (ts)
I am applying for: (check each that you are applying for) q Transesophageal Echocardiography q Stress Echocardiography
Name ___________________________________________________________________________________________________________________ Last/Surname First(FullName) Middle(FullName)
Degree________________________SocialSecurityNumber(last4digits)__________________________________Dateof Birth ______________________________
Mailing Address _________________________________________________________________________________________________________________________
City ____________________________________________ State _______ Zip________________ Country _________________________________________________
Address is (please check one): q Home q Business
TelephoneCountryCode*(OutsideUS&Canada) ___________________________ TelephoneCityCode*(OutsideUSandCanada) _____________________________
Business Telephone ___________________________________________________ Cell Telephone _______________________________________________________
Home Telephone _____________________________________________________ E-mail(required) _____________________________________________________
CardiovascularDiseaseTrainingCompleted(mm/dd/yy) __________________________________________________________________________________________
Important: Please refer to the Policy Notice on page 5 for adding Additional Certification.
Note: It is the responsibility of the applicant to verify that all required documentation is attached to the application. The applicant is also responsible for verifying that notarized letters are correct and in the required format.
Note: Cardiovascular disease training must have been completed prior to July 1, 2009.
Mail, UPS, or FedEx completed application, check list, documentation and payment to: The National Board of Echocardiography, Inc., 1500 Sunday Drive, Suite 102, Raleigh, North Carolina 27607
Make checks payable to National Board of Echocardiography, Inc. or NBE.
FAXED APPLICATIONS WILL NOT BE ACCEPTED.
APPLICATIONS THAT ARE NOT SIGNED WILL NOT BE PROCESSED.
INCOMPLETE APPLICATIONS WILL NOT BE REVIEWED BY THE CERTIFICATION COMMITTEE.
To contact our office: Phone:(919)861-5582 E-mail: [email protected] Web site: www.echoboards.org
18
ChecklistNational Board of Echocardiography, Inc.
Certification for Comprehensive (c), Transthoracic (t), Transthoracic plus Transesophageal (te), and Transthoracic plus Stress (ts) Echocardiography
(ASCeXAM and Conversion from Testamur to Certified Status)Application is for _______________________________________________________________________ Certification.
Name ___________________________________________________________________________________________________________________ Last/Surname First(FullName) Middle(FullName)
SocialSecurityNumber(last4digits)_________________________________________________Dateof Birth ______________________________
__Requirement 1 — Testamur of the Examination of Special Competence in Adult Echocardiography Enter Year Exam Passed: _______________
(If takingASCeXAMin2015enter2015)
__Requirement 2 — Medical License Copyof CurrentMedicalLicenserenewalcertificatethatshows
expiration date
__Requirement 3 — Training in a Medical Sub-specialty Copyof HighestSubspecialtyMedicalBoardCertificate
(Copyof ABIMCertificateinCardiovascularDiseaseispreferred)
__Requirement 4 — Training in Cardiovascular Disease Enter Exact date That Training in CV Disease was completed
(mm/dd/yy)_______________
Supply Oneof theFollowingtoConfirmDateThatTrainingWasCompleted:
- Copyof FellowshipCertificateinCardiovascularDisease
- NotarizedLetteronAppropriateLetterheadFromDivision/ FellowshipDirectorConfirmingtheLengthandDatesof Training
- Notarized Letter on Appropriate Letterhead from the Hospital or AppropriateDepartmentalTrainingDirectorConfirmingDates and Completion of a Full 24 Months of Clinical Training in Cardiovascular Disease
__Requirement 5 — Training in Echocardiography (InformationCANbecombinedintooneletter)
If CV Training was completed Less than 3 years out of Training Go to Section 1
If CV Training was completed Between July 1, 1990 and July 1, 2009 Go To Section 2
If CV Training was completed Before July 1, 1990 Go to Section 3
Section 1: Cardiovascular Training was completed less than 3 years out of training__ Notarized Letter from Training Director or Division Head docu-
menting Achievement of Level II Training in Echocardiography stating the dates of training and the number of Transthoracic Echocardiogramsperformedduringtraining.(c,t,te,ts)
__ Notarized Letter documenting the number of Transesophageal Echocardiogramsperformedduringtraining.(c,te)
__ Notarized Letter documenting the number of Stress Echocardiograms performedduringtraining.(c,ts)
__ Notarized Letter from Training Director stating that the applicant is competent to perform as an independent echocardiographer. (seesampleletter,page21)
Section 2: Cardiovascular Training was completed BETWEEN July 1, 1990 and July 1, 2009__ Notarized Letter documenting the number of Transthoracic
Echocardiograms performed per year in each of the preceding two(2)years.(c,t,te,ts)
__ Notarized Letter documenting the number of Transesophageal Echocardiograms performed per year in each of the preceding two(2)years.(c,te)
__ Notarized Letter documenting the number of Stress Echocardiograms performedperyearineachof theprecedingtwo(2)years.(c,ts) (seesampleletter,page22orpage23)
Section 3: Cardiovascular Training was completed BEFORE July 1, 1990__ Notarized Letter documenting the number of Transthoracic
Echocardiograms performed per year in each of the preceding three(3)years.(c,t,te,ts)
__ Notarized Letter documenting the number of Transesophageal Echocardiograms performed per year in each of the preceding two(2)years.(c,te)
__ Notarized Letter documenting the number of Stress Echocardiograms performedperyearineachof theprecedingtwo(2)years.(c,ts) (seesampleletter,page22orpage23)
Note: It is the responsibility of the applicant to verify that all required documentation is attached to the application. The applicant is also responsible for verifying that notarized letters are correct and in the required format.
RETURN THIS CHECKLIST WITH APPLICATION AND DOCUMENTATION TO: National Board of Echocardiography, Inc., 1500 Sunday Drive, Suite 102, Raleigh, NC 27607
19
ChecklistNational Board of Echocardiography, Inc.
Certification in Transesophageal Echocardiography (e) for Cardiovascular Anesthesiologist or Cardiovascular Surgeon
(ASCeXAM and Conversion from Testamur to Certified Status)Application is for Transesophageal Certification.
Name ___________________________________________________________________________________________________________________ Last/Surname First(FullName) Middle(FullName)
SocialSecurityNumber(last4digits)_________________________________________________Dateof Birth ______________________________
__Requirement 1
Enter Year Exam Passed: _______________ (If takingASCeXAMin2015enter2015)
__Requirement 2
Copyof CurrentMedicalLicenserenewalcertificatethatshows expiration date
__Requirement 3
Copyof HighestSubspecialtyMedicalBoardCertificate
__Requirement 4
Enter Exact date that training in CV Disease was completed (mm/dd/yy)_______________
Supply Oneof theFollowingtoConfirmDateThatTrainingWasCompleted:
- copyof FellowshipCertificateinCardiovascularDisease
- NotarizedLetteronAppropriateLetterheadFromDivision/ FellowshipDirectorConfirmingtheLengthandDatesof Training
- Notarized Letter on Appropriate Letterhead from the Hospital or AppropriateDepartmentalTrainingDirectorConfirmingDates and Completion of a Full 24 Months of Clinical Training in Cardiovascular Disease
__Requirement 5 (pages 8-9)
Training in Echocardiography:
If CV Training was completed after July 1, 2009 Go to Section 1
If CV Training was completed Between July 1, 1990 and July 1, 2009 Go to Section 2
If CV Training was completed Prior to July 1, 1990 go to Section 3
Section 1: Cardiovascular Training was completed less than 3 years out of training
__ Notarized Letter documenting the number of Transesophageal Echocardiograms performed during training.
Section 2: Cardiovascular Training was completed BETWEEN July 1, 1990 and July 1, 2009
__ Notarized Letter documenting the number of Transesophageal Echocardiograms performed during training.
AND
__ Notarized Letter documenting the number of Transesophageal Echocardiograms performed per year in each of the preceding two(2)years.
Section 3: Cardiovascular Training was completed BEFORE July 1, 1990
__ Notarized Letter documenting the number of Transesophageal Echocardiograms performed per year in each of the preceding three(3)years.
Note: It is the responsibility of the applicant to verify that all required documentation is attached to the application. The applicant is also responsible for verifying that notarized letters are correct and in the required format.
RETURN THIS CHECKLIST WITH APPLICATION AND DOCUMENTATION TO: National Board of Echocardiography, Inc., 1500 Sunday Drive, Suite 102, Raleigh, NC 27607
20
ChecklistNational Board of Echocardiography, Inc.
Change in Certification
Application is for Additional Certification in: (check all that apply) q Transesophageal Echocardiography q Stress Echocardiography
Name ___________________________________________________________________________________________________________________ Last/Surname First(FullName) Middle(FullName)
SocialSecurityNumber(last4digits)___________________________________________________________Dateof Birth ____________________
__Requirement 1
Enter Year Exam Passed:________
Enter Date Cardiovascular Disease Training was completed:________
Note: Cardiovascular Disease Training must have been completed prior to July 1, 2009.
__Requirement 2 (page 10)
Maintenance of skills in echocardiography (InformationCANbecombinedintooneletterif applyingfor additionalcertificationinbothTransesophagealandStress Echocardiography)
__ Transesophageal: Performance and interpretation of at least 50 transesophageal echocardiogramsperyearforeachof thetwo(2)yearsimmediatelypreceding this application.
- Notarized Letter documenting the number of Transesophageal Echocardiograms performed per year in each of the preceding two(2)years.
__ Stress: Primary interpretation of at least 100 stress echocardiograms per year foreachof thetwo(2)yearsprecedingthisapplication.
- Notarized Letter documenting the number of Stress Echocardio-gramsperformedperyearineachof theprecedingtwo(2)years.
Note: It is the responsibility of the applicant to verify that all required documentation is attached to the application. The applicant is also responsible for verifying that notarized letters are correct and in the required format.
RETURN THIS CHECKLIST WITH APPLICATION AND DOCUMENTATION TO: National Board of Echocardiography, Inc., 1500 Sunday Drive, Suite 102, Raleigh, NC 27607
Important: Please refer to the Policy Notice on page 5 for adding Additional Certification.
21
ABC Hospital123 Main Street • New York, NY 54321 • (212) 123-5432
Date
National Board of Echocardiography, Inc. 1500 Sunday Drive, Suite 102 Raleigh, NC 27607
RE: Physician’s Full Name Physician’s Date of Birth Physician’s Social Security Number ACGME Program Number
To Whom It May Concern:
Requirement 4: This letter serves to confirm that Dr. ____________________ successfully completed a minimum of 24 months of clinical cardiology training at our institution between ____________________ and ____________________ including completion of Level II echocardiography training and at least 6 months specific training in the Echocardiography laboratory. This letter further confirms that this program is an accredited ACGME training program or other nationally accredited cardiovascular disease training program.
Requirement 5: Our laboratory records indicate that __________ performed and interpreted echoes during training as follows:
Transthoracic Echoes (2-D and Doppler) Performed __________ Transthoracic Echoes (2-D and Doppler) Interpreted __________ Transesophageal Echoes Performed and Interpreted __________ Stress Echoes Participated In and Interpreted __________
In my opinion Dr. ____________________ has the clinical competence and professional qualities necessary to perform as an independent echocardiographer.
q I certify that the number of studies provided above are exact numbers and are not rounded and/or estimates. (Please check box.)
Sincerely,
Name Title (Division or Department Head or Fellowship Training Director)
Sworn and subscribed to before me on (date): ____________________________________
_______________________________________________________________________ Signature of Notary Public
* NOTE: For the purpose of Certification, a study performed and/or interpreted may be counted only once and must be counted under the code that it was billed. Example: Even though a full TTE is performed as part of a Stress Echo with only a single bill being submitted (93350), the study must be counted as a Stress Echo and cannot be counted as both a TTE and a Stress.
The EXACT number of studies performed and interpreted MUST be provided. Applications containing approximated and/or rounded numbers will no longer be reviewed by the Certification Committee. Letters documenting training MUST be on appropriate letterhead, MUST BE NOTARIZED, and MUST be the original letter.
Sample Letter
John Doe
(name)
Notary Seal
For physicians who completed fellowship Less Than 3 years out of Training
(he/she)
(date) (date)
(name)
(#)(#)(#)(#)
22
Sample Letter
Jane Smith
Notary Seal
For physicians who completed fellowship PRIOR to July 1, 2009 and are in private practice
(name)(he/she)
ABC Practice123 Main Street • New York, NY 54321 • (212) 123-5432
Date
National Board of Echocardiography, Inc. 1500 Sunday Drive, Suite 102 Raleigh, NC 27607
RE: Physician’s Full Name Physician’s Date of Birth Physician’s Social Security Number
To Whom It May Concern:
ThisletterservestoconfirmthatDr.____________________isapracticingcardiologistinprivatepractice.Ourrecordsindicatethat __________ has performed and interpreted echoes as follows:
Yr.1(2012) Yr.2(2013) Yr.3(2014) Transthoracic(93303-93308)* #### #### #### Transesophageal(93312-93317)* #### #### StressEcho(93350)* #### ####
q Icertifythatthenumberof studiesprovidedaboveareexactnumbersandarenotroundedand/orestimates. (Please check box.)
Sincerely,
Name Title(President,CEO,orBusinessManager)
Sworn and subscribed to before me on (date): ____________________________________
_______________________________________________________________________ Signature of Notary Public
* NOTE: For the purpose of Certification, a study performed and/or interpreted may be counted only once and must be counted under the code that it was billed. Example: Even though a full TTE is performed as part of a Stress Echo with only a single bill being submitted (93350), the study must be counted as a Stress Echo and cannot be counted as both a TTE and a Stress.
The EXACT number of studies performed and interpreted MUST be provided. Applications containing approximated and/or rounded numbers will no longer be reviewed by the Certification Committee. Letters documenting level of service MUST be on appropriate letterhead, MUST BE NOTARIZED, and MUST be the original letter.
NOTE: The numbers provided must be in parallel, consecutive years but need not be calendar years. The end of the most recent year for which credit is requested must fall within the 12 months prior to receipt of the complete application.
23
XYZ Hospital123 Main Street • New York, NY 54321 • (212) 123-5432
Date
National Board of Echocardiography, Inc. 1500 Sunday Drive, Suite 102 Raleigh, NC 27607
RE: Physician’s Full Name Physician’s Date of Birth Physician’s Social Security Number
To Whom It May Concern:
This letter serves to confirm that Dr. ____________________ is a practicing cardiologist working in our Echocardiography Lab. Our records indicate that __________ has performed and interpreted echoes as follows:
Yr. 1 (2012) Yr. 2 (2013) Yr. 3 (2014) Transthoracic (93303-93308)* #### #### #### Transesophageal (93312-93317)* #### #### Stress Echo (93350)* #### ####
q I certify that the number of studies provided above are exact numbers and are not rounded and/or estimates. (Please check box.)
Sincerely,
Name Title (Medical Director)**
Sworn and subscribed to before me on (date): ____________________________________
_______________________________________________________________________ Signature of Notary Public
* NOTE: For the purpose of Certification, a study performed and/or interpreted may be counted only once and must be counted under the code that it was billed. Example: Even though a full TTE is performed as part of a Stress Echo with only a single bill being submitted (93350), the study must be counted as a Stress Echo and cannot be counted as both a TTE and a Stress.
The EXACT number of studies performed and interpreted MUST be provided. Applications containing approximated and/or rounded numbers will no longer be reviewed by the Certification Committee. Letters documenting training MUST be on appropriate letterhead, MUST BE NO-TARIZED, and MUST be the original letter.
NOTE: The numbers provided must be in parallel, consecutive years but need not be calendar years. The end of the most recent year for which credit is requested must fall within the 12 months prior to receipt of the complete application.
** In the absence of a formal director of the echocardiography laboratory, the letter should be written by an appropriate supervising physi-cian. If applicant is the Medical Director of the Echocardiography Laboratory, the letter should be from the Chief of Cardiology or the Chief of Staff of the Hospital.
Sample Letter
Joe Jones
Notary Seal
For physicians who completed fellowship PRIOR to July 1, 2009 and work in a hospital setting
(name)(he/she)