23
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

Application for Certification Adult Echocardiography (ASCeXAM) · Certification Adult Echocardiography (ASCeXAM) ... certification) by obtaining additional training in an ACGME ac-credited

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Page 1: Application for Certification Adult Echocardiography (ASCeXAM) · Certification Adult Echocardiography (ASCeXAM) ... certification) by obtaining additional training in an ACGME ac-credited

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

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2

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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.

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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.

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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.

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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.

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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)

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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.

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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.

Page 10: Application for Certification Adult Echocardiography (ASCeXAM) · Certification Adult Echocardiography (ASCeXAM) ... certification) by obtaining additional training in an ACGME ac-credited

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.

Page 11: Application for Certification Adult Echocardiography (ASCeXAM) · Certification Adult Echocardiography (ASCeXAM) ... certification) by obtaining additional training in an ACGME ac-credited

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

Page 12: Application for Certification Adult Echocardiography (ASCeXAM) · Certification Adult Echocardiography (ASCeXAM) ... certification) by obtaining additional training in an ACGME ac-credited

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.

Page 13: Application for Certification Adult Echocardiography (ASCeXAM) · Certification Adult Echocardiography (ASCeXAM) ... certification) by obtaining additional training in an ACGME ac-credited

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

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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

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LASTNAME

FIRSTNAME

MIDDLENAME

ID#

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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).

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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

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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

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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

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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

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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.

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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)

(#)(#)(#)(#)

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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.

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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)