STS Election Form Regarding Surgeon-Specific Reporting

THE SOCIETY OF THORACIC SURGEONS NATIONAL DATABASE
Election to Receive Surgeon-Specific Reports
Adult Cardiac Surgery Database

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 Duke Clinical Research Institute) (the “Service Provider”) 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 Provider my own Individual Surgeon Composite Measure scores computed in accordance with the methodology developed and published by STS (Ann Thorac Surg 2015;100:1315-25), as said methodology may be revised from time to time (each a “Surgeon-Specific Report”). I understand that each Surgeon-Specific Report will only be made available to me by the Service Provider for viewing and downloading at an online portal accessible only through personal login credentials issued to me by the Service Provider. 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 Provider 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 STS and the Service Provider will only make Surgeon-Specific Reports available to me through the unique login credentials issued to me by the Service Provider, and that the email address provided below will be used to send communications to me regarding this 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 Provider only include data regarding procedures that I performed when computing my own Individual Surgeon Composite Measure performance and preparing/ sending the Surgeon-Specific Reports, and I hereby authorize STS and the Service Provider 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 Provider and their representatives harmless in connection with their actions taken in good faith reliance on this Election Form.