Subscriptions are valid for one year and are renewable annually or until end of Residency or Fellowship training.
Authorization to Release Information
While an Applicant for Membership and if elected to membership in the American Society of Plastic Surgeons®
(ASPS or the “Society”), I agree to abide by the Society’s Bylaws and Code of Ethics. I understand that membership
in ASPS is a privilege and not a right. As an applicant for membership, I have the responsibility of providing
information adequate for proper evaluation of my fitness for membership in ASPS.
In furtherance of my application for membership in ASPS, I hereby request and authorize any hospital, any medical
staff, any medical organization and any person who may have information (including
medical records, patient records and reports of committees) that they deem relevant to my fitness for
membership to provide such information to the Society. I further authorize the Society to provide any information
it receives in connection with my application for membership in the Society to a state or county licensing
authority, a state or county medical association, or an accrediting body provided I have authorized the licensing
authority, medical association, or accrediting body to obtain such information.
The Society shall not be liable for acts performed in connection with the collection, evaluation, or
dissemination of information or opinions, whether or not requested or solicited, in connection with
my application for membership in the Society. I shall not demand, through any judicial process, access to any
information accumulated or prepared by the Society in considering my application for membership.
Name (Printed): ___________________________________________________________________
Please submit application to:
ASPS Member Services
American Society of Plastic Surgeons 444 E. Algonquin Road
Arlington Heights, IL 60005-4664
Or email to: firstname.lastname@example.org
Or fax to: +001 847-228-7099
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