Ophthalmic Surgical Assisting Certification (OSA)
Clinical Documentation for CMS Rule
This form serves as documentation that my Ophthalmic Medical Assisting and Scribe Staff are
JCAHPO certified and JCAHPO has attested to their achievement of the knowledge and skills.
(Employee Name) is employed by
(Physician/Practice Name). HE/SHE is JCAHPO certified as
and has demonstrated successful completion of examination on the knowledge and skill as follows:
_______ Certified Ophthalmic Assistant (COA®)
_______ Certified Ophthalmic Technician (COT ®)
_______ Certified Ophthalmic Medical Technologist (COMT ®)
_______ Ophthalmic Scribe Certified (OSC ®)
A copy of my employee’s certificate of JCAHPO Certification is attached.
As the employer, I attest that my employee who is JCAHPO certified performs the following Ophthalmic Medical
Assisting or Scribe duties.
COA, COT, and COMT Certification Content Knowledge & Skills
Select All
That Apply
Current Tasks Performed
Select All
That Apply
Current Task Performed
History Taking
Pupillary Assessment
Contact Lenses
Equipment Maintenance and Repair
Lensometry
Keratometry
Medical Ethics, Legal, and Regulatory Issues
Microbiology
Pharmacology
Ocular Motility
Assisting in Surgical Procedures
Ophthalmic Patient Services and Education
Ophthalmic Imaging
Refractometry
Spectacle Skills
Supplemental Skills
Tonometry
Visual Assessment
Visual Fields
Scribe Certification Content Knowledge & Skills
History Taking
Ophthalmic Patient Services and Education
Ophthalmic Terminology
Medical Ethics & Legal Issues
The Medical Note/Records
Employer Signature
Date
17