STS Election Form Regarding Surgeon-Specific Reporting
THE SOCIETY OF THORACIC SURGEONS NATIONAL DATABASE
Election to Receive Surgeon-Specific Reports
I, the undersigned, by this Election Form, give permission to The Society of Thoracic Surgeons (“STS”) and any provider of data warehousing and/or analytics services it retains in connection with the operation of the STS National Database (currently the STS Research and Analytic Center and Outcome Sciences, Inc. d/b/a IQVIA) (the “Service Providers”) to use the data that (i) is submitted to the STS National Database in accordance with the STS National Database Participation Agreement upon which my name appears within Schedule A thereto (the “Participation Agreement”), and (ii) concerns procedures associated with my National Provider Identifier (“NPI”), to prepare and make available to me through the Service Providers my own surgeon-specific report. I understand that each surgeon-specific report will only be made available to me by STS as an email attachment or for viewing and downloading at an online portal accessible only through personal login credentials issued to me by one of the Service Providers. I understand that surgeon-specific reports are to be used solely for the purposes of surgeon self-assessment and quality improvement, and are not for public or other external release.
I understand that only by my signing this Election Form will STS and the Service Providers be authorized to prepare and make available to me any surgeon-specific report. I also understand that I may modify my election to change my email address, and may withdraw my election, by transmitting to STS one or more subsequent Election Form(s). I understand that the email address provided below will be used to send communications to me regarding this surgeon-specific reporting program, including announcements of the availability of each new surgeon-specific report.
I understand that I must provide my NPI in the form below to ensure that STS and the Service Providers only include data regarding procedures that I performed when generating, preparing, and sending my own surgeon-specific reports, and I hereby authorize STS and the Service Providers to use my NPI for that purpose. I hereby attest that the NPI submitted herewith is correct.
I agree that this Election Form does not amend the Participation Agreement, and that the Participation Agreement remains in full force and effect. I agree to hold STS, the Service Providers and their representatives harmless in connection with their actions taken in good faith reliance on this Election Form.
