APPLICATION FOR MAINTENANCE OF CERTIFICATION

APPLICATION FOR MAINTENANCE OF CERTIFICATION

IN FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY?

by the American Board of Facial Plastic and Reconstructive Surgery, Inc.?

Application Postmark Deadline: January 15, 2018

ABFPRS

115C South Saint Asaph Street Alexandria, VA 22314 Phone: (703) 549-3223 Fax: (703) 549-3357 application@

?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, 2018. 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, rather than 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

4

6. Preferred E-mail: ________________________________________________________________

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

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download