Gynecologic Surgery Physician Membership Application

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Gynecologic Surgery Physician Membership Application

Step 1 of 4

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13506 Summerport Village Pkwy.
Box 253
Windermere, FL 34786
Phone 407-376-3110
Fax 407-850-0293
www.AIMIS.org
Gynecologic Surgery Physician Membership Application
Contact Information
Hospital / Institute Name:*
Address: Suite City State / Province / Region ZIP / Postal Code Country
CEO:
CEO Phone #:
Extension
CMO:
CMO Phone #:
Extension
Director of Surgery:
Director Of Surgery Phone #:
Extension
Administrative Assistant:
Admin Assistant Phone #:
Extension
Contact Representative (person completing application):
Phone
Email
Fax
Other:
Please describe:

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GYN Surgical Data
Hospital-Based Surgeries completed in 2017
Please break out Straight Stick and Robot Assist as part of the total number
LSH Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
Total
SS
RA
TLH Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
Total
SS
RA
LAVH Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
Total
SS
RA
TVH Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
TAH Procedure CPT Codes
(Procedure codes can be located in current coding manuals)
AIMIS GYN PHYSICIAN MEMBERSHIP

Accredited Physician – Surgeons at this membership level have advanced their surgical skills and have become accredited by AIMIS. As an accredited member, the Doctor provides procedural and outcome data and is recognized as a selected surgeon with surgical benefits. A surgeon can designate any or all surgeries to be recognized as accredited. The following criteria:
O.R.-Based Surgeries: MI Hysterectomy: Performs TLH/LSH/LAVH/TVH 60% of cases done TLH/LSH/LAVH/TVH per year Complication rate Under 3% of major complication rate Office-Based Procedures ______Hysteroscopy ______Endometrial Ablation ______Transcervical Tubal Ligation • Member in “Good Standing” • Cases reported with complications • Code of Conduct: Adheres to AI-MIS policies • Board Certification/Board Eligible • Attended: At least 1 MIS courses in the past 24 months at sign-up • Attends: At least 1 MIS course per 24 months Authorization I authorized the American Institute of Minimally Invasive Surgery to obtain information from your institution and outside agencies. With my signature, I proclaim that all the information provided is accurate to the best of my knowledge.
Name*
First Last
Date*
File Upload
CV*
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Hospital Biography
Accepted file types: doc, docx, pdf.
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GYN PHYSICIAN MEMBERSHIP: 450 USD
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Gynecologic Surgery Physician Membership Application

Gynecologic Surgery Physician Membership Application

Step 1 of 4

Gynecologic Surgery Physician Membership Application

Contact Information

Academic Affiliation:

1. Other Hospital Location(s):

2. Other Hospital Location(s):

AIMIS Survey Questions for Initial Application and Survey

GYN Surgical Data

Hospital-Based Surgeries completed in 2017

AIMIS GYN PHYSICIAN MEMBERSHIP

File Upload

GYN PHYSICIAN MEMBERSHIP: 450 USD