Application for Active Membership

Application for Active Membership

Please review the below items carefully, and ensure your application is complete before submission. The review process will take several months, so the deadline is absolute. Requirements include:

1. Board-certification by the American Board of Plastic Surgery (ABPS) or the Royal College of Physicians and Surgeons of Canada (RCPSC).

2. Attendance at The Aesthetic Meeting or an ASAPS Symposium exclusively organized and managed by the Society within 4 years prior to submission of this application (Qualifying meetings are listed on ).

3. All published advertising must be submitted with this application, including newspaper, magazines and Yellow Page ads. You must also enclose a copy of all patient education information (brochures) and all marketing or promotional materials. Provide all website addresses and or social media links (printed copies from the internet are not required. A committee will review all websites and social media at length).

4. A recent photograph (taken within 1 year). Please attach to the application where noted, or include as a .jpeg attachment with your application email submission.

5. The names of two (2) sponsors must be listed on the application. Both sponsors must be an ASAPS Active or Life Member, one of which must be within 100 miles of your practice. The sponsor forms must be sent to them by you, via email, with the instructions to return them directly to the Central Office via email. Sponsors may not be family members, partners or associates in the same practice.

6. The enclosed procedural case summary form must be completed for a recent 12-month period.

7. The enclosed statement must be completed attesting to your compliance with ASAPS Bylaws Article XIII, regarding Accredited Surgical Facilities.

8. The enclosed malpractice carrier information and claims history forms must be completed.

9. Payment of the application fee in the amount of $250.00 (U.S. Dollars) payable to The American Society for Aesthetic Plastic Surgery, Inc. must be included.

10. Optional: Submit a personal statement telling us about yourself and why you want to be an Active member of The Aesthetic Society. The statement should be attached with your application as a PDF.

The application must be completed via fillable PDF (handwritten applications will not be accepted). The application, sponsor forms and any other material relevant to your application must be submitted via email. Applications not completed by the deadline, including sponsorship forms, will be held until the next deadline. Failure to comply with the above requirements may be cause for a delay of evaluation of your application.

All materials must be submitted by the January 5 or July 1 deadline to:

Marissa Simpson, Membership Manager, E-mail: membership@ 11262 Monarch Street, Garden Grove, CA 92841, USA 562/799-2356

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APPLICATION FOR ACTIVE MEMBERSHIP

First Name:

Middle Initial:

Office Address (including name of practice):

Last Name:

Office Phone:

Cell Phone:

Date of Birth:

Citizenship:

Medical School:

Surgery Residency (Specialty, Institution, Location and Dates):

E-mail: _ Gender: Male Female Graduation Date:

Plastic Surgery Residency and related Fellowships (including names of Institution, Location, Program Directors and Dates):

Certification by The American Board of Plastic Surgery or The Royal College of Physicians and Surgeons of

Canada: Date:

Certificate #:

Date of Recertification:

Certification by other Specialty Boards (date and certificate number):

Name:

Date:

Cert. #

Name:

Date:

Cert. #

Name:

Date:

Cert. #

I have been practicing plastic surgery at the following location(s) (starting with the most recent, including dates):

Year(s) attended The Aesthetic Society annual meeting(s) or a meeting exclusively organized and managed by the Society: Other Professional Society Memberships: Current Academic Appointments and Affiliations: Hospitals in which you hold staff appointment (indicate active or courtesy):

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APPLICATION FOR ACTIVE MEMBERSHIP

Have you ever been denied membership in any professional organization, OR

resigned while under investigation?

Yes

No (If yes, please explain on separate page.)

Have you ever been sanctioned or censured by any professional organization?

Yes

No (If yes, please explain on separate page.)

Have you ever had hospital staff privileges suspended, revoked, been censured or

been placed on probation?

Yes

No (If yes, please explain on separate page.)

Has a malpractice carrier ever denied you coverage?

Yes

No (If yes, please explain on separate page.)

RECENT PHOTOGRAPH (WITHIN ONE YEAR)

Have you ever been named a defendant in malpractice actions, past or pending?

Yes

No (If yes, please explain on separate page.)

Have you ever had your medical license or narcotics license suspended, revoked or been placed on probation by a licensing

authority for any reason, including drugs or alcohol?

Yes

No (If yes, please explain on separate page.)

Name of sponsors (2), both of whom must be Active/Life members of the Society. Sponsors may not be family members, partners or associates in the same practice. *One must be from your immediate geographic area.

1.*

2.

AUTHORIZATION TO RELEASE INFORMATION, RELEASE OF LIABILITY AND WAIVER OF RIGHTS

To permit review and consideration of my application for membership in the American Society for Aesthetic Plastic Surgery, Inc., I request and authorize any medical institution, medical society, hospital medical staff, medical organization, and any person who may have information (including, but not limited to, medical records, patient records, and reports of committees) which they consider relevant to my fitness for membership, to provide such information to the American Society for Aesthetic Plastic Surgery, Inc.

I further specifically authorize the release of all information pertaining to all my records compiled by any and all professional liability insurance companies which have issued me policies covering my medical practice presently or in the past.

I release from liability any such medical institution, medical society, hospital, medical staff, medical organization or person, professional liability insurance company or companies and the American Society for Aesthetic Plastic Surgery, Inc. from liability for acts performed in connection with the providing of, collecting of, or evaluation of information or opinion, whether or not requested or solicited, regarding my application for membership in the American Society for Aesthetic Plastic Surgery, Inc. I understand that if any information or material provided in my application is found to be false, fraudulent, deceptive or misleading, my application will be denied. I also understand that if my application is accepted prior to discovery of this information, my membership may be administratively revoked.

I also agree and promise not to demand, and I waive any rights that I might have to demand, through the judicial process, access to any information accumulated or prepared in considering my application. This waiver shall apply in any suit, special proceeding, claim or demand based on any type of cause of action whatsoever.

I have read, understand and agree to comply with the Bylaws, Conflict of Interest Policy and the Code of Ethics of the American Society for Aesthetic Plastic Surgery, Inc. and further agree to pay all dues and assessments promptly.

*BY SIGNING BELOW, I CERTIFY THAT ALL INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND CORRECT.

Signature:

Date:

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PROCEDURAL CASE SUMMARY

Please list the number of cases you have performed in each category over the last year (12 months) Do not include any treatments that were performed by a nurse or aesthetician, even if done under your supervision.

PROCEDURE Breast Augmentation Breast Implant Removal Breast Lift Breast Reconstruction Breast Reduction Breast Reduction Brow Lift Buttock Augmentation Buttock Lift Chin Augmentation Ear Surgery Eyelid Surgery Facelift

Fat Transfer

Hair Transplantation Labiaplasty Liposuction Lip Augmentation Lower Body Lift Neck Lift Nose Surgery Thigh Lift Tummy Tuck Upper Arm Lift Upper Body Lift

EXPLANATION

Including nipple and areola reconstruction Male (for the treatment of Gynecomastia) Female

Implants Only

For upper and lower count as two (2) Any technique Breast, Buttock, Face and Other. Count each area separately, paired areas count as one (1) Include scalp reduction, flaps for baldness and hair grafts

Count each area separately, paired areas count as one (1) Not including injectables

# OF CASES

Total of Surgical Cases (above) Total of Non-Surgical Aesthetic Cases* Grand Total of All Procedures

*Non-Surgical Aesthetic Cases include: Filler Injection, Chemical Peel, Laser Hair Removal, Laser Skin Resurfacing, Laser Vaginal Rejuvenation, Neurotoxin Injection, Non-Surgical Fat Reduction and Non-Surgical Skin Tightening.

I attest that I have personally performed the number and types of cases described above from the past year (12 months). I understand that I may be asked to substantiate and will provide additional information as required.

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MALPRACTICE CLAIMS HISTORY

Please provide carrier information for the past five years. This form must be completed regardless of history of malpractice cases.

Present Carrier's Name

Complete Address:

Policy Number:

Coverage Amounts:

Date of Coverage: From_

To

Present Carrier's Name:

Complete Address:

Policy Number:

Coverage Amounts:

Date of Coverage: From

To

Previous Carrier's Name

Complete Address:

Policy Number: Date of Coverage: From Present Carrier's Name:

Coverage Amounts: To

Complete Address:

Policy Number: Date of Coverage: From

Coverage Amounts: To

Please list any currently pending and past malpractice claims, judgment or settlements involving your professional practice:

Pending Claims (open): Judgments for: Plaintiffs: Out of Course Settlements: Non-suited/Dropped/Dismissed:

Defendant:

Total:

(Please provide case summary for each case using the following form)

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CASE SPECIFIC MALPRACTICE CLAIMS INFORMATION

The following information is necessary to complete this application and will be kept confidential. Please print or type answers to the following for any malpractice claims opened, closed, settled or paid. Please complete a separate form for each claim, one case per sheet. If not applicable, list "N/A".

1. Initials of Patient involved: Month and Year of Occurrence: Month and Year of Lawsuit: Insurance Carrier at Time: 2. What is/was your status: Primary Defendant:

Age of Patient:

Co-Defendant:

Other: (Please explain)

Please list other Defendants:

3. What was the patient's outcome?

4. How were you alleged to have cause harm or injury to this patient?

5. Please provide specifics in reference to the adverse event:

6. What is/was your role in this event?

7. Current Status:

Still Pending:

as of (date):

If still pending, when was last contact with Plaintiffs attorney?

Trail date set, awaiting trial:

Trial date:

_

Settled out of court?

Date:

Amount of Settlement: $

(Non-suited) dropped: Date:

Judgment amount Date:

Amount paid by you: $

This Claim Information Form is requested on all claims/lawsuits that are reported by your malpractice insurance carrier and/or the National Practitioner Data Bank. Please feel free to submit a complete summary of your malpractice claims in addition to this document.

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STATEMENT OF ASAPS ACCREDITATION COMPLIANCE

Facility accreditation is a requirement for Active Membership in the American Society for Aesthetic Plastic Surgery, Inc. According to Article XIII: Accredited Surgical Facilities of the ASAPS Bylaws, require facility accreditation for surgery performed under anesthesia, other than local anesthesia and/or minimal oral or intramuscular tranquilization.

A surgical facility that meets at least one of the following criteria: a) accredited by National or State recognized accrediting agencies/organizations; or b) certified to participate in the Medicare program under Title XVIII and/or licensed by the state where the facility is located. Compliance is a requirement of membership and each member shall annually sign and return to the Aesthetic Society a statement attesting to compliance. Upon request, compliance shall be waived for Active Members Serving in the military.

Failure to comply with the Aesthetic Society accredited surgical facility requirement will lead to sanctions up to and including expulsion from membership. After expulsion for (1) year, a previous member may apply to Trustees for reinstatement as an ASAPS member, provided the requirements are fulfilled.

1. List the name and address of each facility where you have surgicalprivileges. 2. Check ) the box indicating how each facility meets the ASAPS Article XIII Bylaws requirement. 3. *If a state approved agency is selected, list the name of the agency below. 4. Sign and date form.

Facility Name and Address

AAAASF

AAAHC

JCAHO

CAAASF

Medicare

State Licensure

State Approved Agency*

*State Approved Agency (provide name & license number): The surgical facility I practice in does not fall into one of the above categories because (check all that apply):

It is a military facility It is outside the USA or Canada Other (please explain) I hereby certify that I am in compliance with the Article XIII of the ASAPS Bylaws

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ADVERTISING GUIDELINES

When your application for membership is received in the Central Office, it is considered to be complete. Please ensure that you have submitted all advertising currently being used and that you have read the ASAPS Bylaws, Conflict of Interest Policy and the Code of Ethics to ensure that all advertising complies with the set standards of the Society.

Your website(s), social media and print advertising will be reviewed at length by The Application Review and Ethics Committees. Be sure that you have not used the logo or wording to indicate that you are associated with the Society. If you are a member of a group practice that uses the logo, please remember that Active Members of the Society should have an asterisk (*) by their names to denote membership in The Aesthetic Society. You are ultimately responsible for the content of your website(s), social media or any links. Please review all sites to make sure that everything is in compliance. Photographs used in your advertising should include the word "model" if it is not an actual patient. We recommend performing a Google search on your name to review any websites that may contain your information.

In addition, we advise you to look at your advertising carefully prior to submission and avoid the use of words that give an impression of superiority or unrealistic results. You may NOT use the word "expert", "international expert" or "expertise in". Self-promotion without factual backup is prohibited. Examples of phrases to avoid include but are not limited to:

Extraordinary results Leader in field Well known for exceptional results The very best Artistic ability Creating masterpieces Gifted surgeon Choose the best Gender-based statements suggesting superiority

Use of these words can result in your application being tabled (for one year) or denied (re-application allowed after two years). I have read and understand the above listed information.

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