Application for Maintenance of Certification in Facial Plastic and Reconstructive Surgery®
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APPLICATION FOR MAINTENANCE OF CERTIFICATION IN FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY® by the American Board of Facial Plastic and Reconstructive Surgery, Inc.Ò Application Postmark Deadline: January 15, 2019 ABFPRS 115C South Saint Asaph Street Alexandria, VA 22314 Phone: (703) 549-3223 Fax: (703) 549-3357 [email protected] www.abfprs.org ©American Board of Facial Plastic and Reconstructive Surgery, Inc® ABFPRS APPLICATION FOR MAINTENANCE OF CERTIFICATION IN FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY® REGISTER FIRST! Applicants for Maintenance of Certification in Facial Plastic and Reconstructive Surgery (MOC in FPS®) must register their intent to participate in this program BEFORE submitting their application. Both online and PDF registration forms are available on the ABFPRS website under For Physicians, Maintaining Certification, Step One. From the date of registration, applicants have three years to complete MOC in FPRS® requirements. INTRODUCTION Read all instructions carefully and study the booklet Information about Maintenance of Certification in Facial Plastic and Reconstructive Surgery® before entering any information. Applicants bear the sole responsibility for preparation of the application, meeting all eligibility criteria, application deadlines, and submission requirements. Only applications that are complete, clear, and accurate will be reviewed. Incomplete applications will be returned for correction, and the delay may jeopardize timely review of an application for the current recertification cycle. Keep a copy of your completed application and all supporting documents for reference, should a question arise during review of your application. Your original application materials should be postmarked no later than January 15, 2019. Send the application and all supporting documents at one time in the same package to the ABFPRS office in Alexandria, VA. For greater security, send your materials by a service that provides proof of delivery. Applications will be reviewed by the ABFPRS Credentials Committee. If your materials appear complete and ready for the Committee’s review, you will receive an email from the ABFPRS office. If your application materials are incomplete or do not meet professional standards for presentation and attention to detail, your application may be returned to you for correction. This is a fillable form, but the completed form should be printed and included with the rest of your materials when you submit your application to the ABFPRS office. Your application materials should be arranged as described on the following page. Thank you for participating in the ABFPRS Program for Maintenance of Certification in Facial Plastic and Reconstructive Surgery® 2 Your materials should be arranged in the following order in one package for shipping. Please use clips or bands. Do not use a loose-leaf binder. o 1. Completed application and payment o 2. Clip together: • Additional information required by question 12 (if necessary) • Copies of Medical Licenses (copies of online license verification or copies of wallet card are acceptable) • Copies of Board Certifications (copies of congratulatory letter on letterhead or copies of online verification are acceptable) • Facility Accreditations (copies of online facility accreditation verification are acceptable) • Verification of Hospital Staff Privileges • CME and transcripts o 3. Sequential Operative Log o 4. Operative Reports – last 35 patients on your SOL • Staple each report separately – do not run them together • Include CPT code for which you are requesting credit (not required for Canadian applicants) – may be handwritten on report • Arrange in chronological order • Clip or band together Remember to: • Request that your three letters of recommendation be mailed directly to the Board’s office • Keep one copy of all application materials for your reference during the review process • Correctly address your package to: American Board of Facial Plastic and Reconstructive Surgery 115C South Saint Asaph Street Alexandria, VA 22314 3 APPLICATION FOR MAINTENANCE OF CERTIFICATION IN ® FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY PART I: GENERAL INFORMATION 1. Registration Date: _____________________ ___________________ ____________________ Month Day Year 2. Date of Application: _____________________ ___________________ ____________________ Month Day Year 3. Name: ________________________________ ___________________ ____________________ Last First Middle 4. Office Mailing Address: _________________________________________________________________________________ Address Line 1 _________________________________________________________________________________ Address Line 2 ____________________________ __________________________ _______________ __________ City State/Province Country Zip/Postal Code Residential Mailing Address: _________________________________________________________________________________ Address Line 1 _________________________________________________________________________________ Address Line 2 ____________________________ __________________________ _______________ __________ City State/Province Country Zip/Postal Code 5. Telephone Numbers: Daytime: (________) ___________________ Fax: (________) ____________________ Area Code Number Area Code Number If unavailable, message may be left with ______________________________________________ Full Name Residence: (________) ___________________ Fax: (________) ____________________ Area Code Number Area Code Number Cell: (________) ___________________ Area Code Number 6. Preferred E-mail: ________________________________________________________________ 4 7. Enter other information required for FSMB and NPDB access: Date of Birth: _______________________________ __________________________ _______ Month Day Year Social Security Number: ________________________________________________________ Medical School Name: __________________________________________________________ Graduation Date: _________________________ _________________________ ________ Month Day Year PART II: PROFESSIONAL STANDING 8. Issue Date of Current ABFPRS Certificate: ________________________ _________ _______ Month Day Year Expiration Date of Current ABFPRS Certificate: _____________________ _________ _______ Month Day Year 9. Licensure: List all licenses you currently hold or have ever held. Enclose photocopies, displaying expiration dates, of all current licenses (wallet card acceptable). Copies of state medical board online verifications are also acceptable. State/Province License Number Registration Date _______________________________ __________________________________ _______________ _______________________________ __________________________________ _______________ _______________________________ __________________________________ _______________ _______________________________ __________________________________ _______________ _______________________________ __________________________________ _______________ _______________________________ __________________________________ _______________ _______________________________ __________________________________ _______________ _______________________________ __________________________________ _______________ _______________________________ __________________________________ _______________ 5 10. Board Certification: List all boards from which you have earned certification. Enclose a copy of your certificate(s). Copies of online certification verification are also acceptable. Name of Board Date of Certification ________________________________________________________________ ________________ ________________________________________________________________ ________________ ________________________________________________________________ ________________ ________________________________________________________________ ________________ 11. Hospital Appointments, Practice Facilities, and Accreditations: In chronological order, list all past and present hospital appointments and practice facilities. All time in medical practice (civil and military) must be included. For current hospital appointments, provide verification of your hospital staff privileges and copies of facility accreditations. For other practice facilities in which you operate using Level II anesthesia and above, enclose a copy of the facility’s accreditation certificate or letter. Online copies of facility accreditations are acceptable. If you operate in a non-accredited office facility using local anesthesia for your procedures, provide evidence of hospital staff privileges or provide evidence of formal arrangement with a neighboring hospital for transfer of patients needing hospitalization. If you do not have privileges in facial plastic surgery at an accredited hospital, provide an explanation as to why this lack of privileges is not related to adverse action by the accredited institutions listed below. Institution/Setting Location Dates Accrediting Agency* ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________