Affidavit Instructions

Facilities are often subject to name changes, mergers or other operational changes that can affect a facility’s accreditation or result in an agreement to transfer ownership of accreditation. The Intersocietal Accreditation Commission (IAC) asks facilities to notify it of these types of changes so that IAC can ensure that the facility remains in compliance with the relevant accreditation standards despite the change. Below are the instructions for preparing an affidavit. Sample forms are also available from IAC.

Each affidavit regarding a change in ownership must include:

  1. The name and address of the accredited facility;
  2. The name and address of the new owner;
  3. The Employer Identification Number of the new owner;
  4. The type of change (such as merger, dissolution, etc.);
  5. The effective date of the change;
  6. The name of the current Medical Director;
  7. The name of the current Technical Director;
  8. The following statements:
    • A. “I represent and warrant that I have authority to execute this affidavit on behalf of the accredited facility.”
    • B. “Ownership of the accredited facility has changed. To the best of my knowledge and belief, I represent and warrant that at the time of this change in ownership, the new owner:
      • i. had a Medical Director;
      • ii. had a Technical Director; and
      • iii. was in compliance with all IAC Standards, policies, and procedures.”
    • C. “The accredited facility requests that IAC approve this change and modify the facility’s accreditation status accordingly. I acknowledge and agree that a modification of accreditation status may require the submission of additional information and/or fees, and is not final unless reviewed and approved in writing by IAC.”
    • D. “Under penalty of perjury, I certify that this information is accurate, true, and complete.”
  9. An opinion letter from legal counsel confirming authority to execute the Affidavit;
  10. And, a notarized signature.

Each affidavit regarding a change other than a change in ownership must include:

  1. The name and address of the accredited facility;
  2. A description of the change (such as the corporate name, new site, new Medical Director, etc.);
  3. The effective date of the change;
  4. The name of the current Medical Director;
  5. The name of the current Technical Director; and
  6. The following statements:
    • A. “The accredited facility requests that IAC approve this change and modify the facility’s accreditation status accordingly. I acknowledge and agree that a modification of accreditation status may require the submission of additional information and/or fees, and is not final unless reviewed and approved in writing by IAC.”
    • B. “Under penalty of perjury, I certify that this information is accurate, true, and complete.”
  7. A notarized signature is optional.

All questions regarding agreement or ownership changes should be directed to the IAC legal department.