Screen Reader Mode Icon
2023 dues must be paid by January 01, 2023. 

Dues may be paid by check or credit card.  You must complete this survey in order to renew your membership. Please make checks payable to Florida Society of Plastic Surgeons or FSPS.  All payments or installments must be made prior to delinquent date 3/1/2023.

FSPS dues are not deductible as a charitable contribution for Federal Income Tax purposes; however, they may be deductible as a business expense under other provisions of the Internal Revenue Code. 27% ($229.50) of FSPS dues are not deductible in accordance with IRC Sec. 6033
 
Please answer Yes or No to the following questions: In the past year have you...

Question Title

* 1. Please enter your current office information.

Question Title

* 2. Has your license to practice medicine in any state, your license to prescribe drugs or your permit to dispense drugs, been revoked, suspended, restricted in anyway, limited or voluntarily relinquished?     

If so, please email a separate report state the date such action was taken, the name of the Agency, the case or matter number and give a precise description of the circumstances and final action taken. 

Question Title

* 3. Have you been notified to respond to appear before a county or state Medical Society, Board, orCommittee of a hospital, any other Health Care facility on a complaint of any nature, including but not limited to unprofessional or unethical conduct and have been found guilty?

If so, please email a separate report stating the date of the actual not, the organization entity, and provide a detailed description of the circumstances and the nature of the complaint or charge and the final disposition.

Question Title

* 4. Have your privileges at any hospital or other health care facility been revoked, suspended, limited involuntarily, denied or not renewed by such institution? 

If so, please email a separate report stating the date such action was taken, the name of the entity, description of  the action taken, and the basis given.

Question Title

* 5. Has your license to practice medicine in any state, your privileges, either staff or clinical, been placed on probation and/or limited in any respect by such entity?

If so, please email a separate report stating the date such action was taken, the name of the entity , the basis such action was taken, its duration and the date the termination if applicable.

Question Title

* 6. Have you ever been found guilty of medical malpractice, or agreed to monetary settlement of a malpractice claim in excess of $10,000?         

Question Title

* 7. If Yes, Has this information been provided to the Society within the last 5 years?

If no, please email a separate report stating the date such notice and/or suit, the name of the Plantiff(s), the city and State of the Plaintiff residence when under your care, the alleged basis for such claim, and the disposition; if settled or if a verdict was rendered, the amount, the name of the court having jurisdiction over the claim and the case number if suite was filed.

Question Title

* 8. Have you been treated by any other Health care provider, in a formal or practice setting or informally, for alcohol or any substance abuse, including narcotics, central nervous systems, stimulants or depressants?    

If yes, please email a separate report stating the current status of this treatment.

Question Title

* 9. *The above information is provided in accordance with the bylaws requirements of the Florida Society of  Plastic Surgeons and, to the best of my knowledge, is accurate and complete. I agree that continuing to maintain such membership, constitutes my consent to receive all communications sent by or on behalf of the Florida Society of Plastic Surgeons, INC. and its subsidiaries and affiliates, via the communicates vehicle of its preference, including but not limited to Email, Fax, Telephone, Regular Mail, or special expedited mail services.

0 of 9 answered
 

T