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Page 1 of 25
FELLOWSHIP IN MINIMALLY INVASIVE GYNECOLOGIC SURGERY (FMIGS)
AGREEMENT
Table of Contents
Introduction .............................................................................................................................................. 2 Mission Statement ................................................................................................................................... 2 Goals ......................................................................................................................................................... 2 Fellowship Training Program .................................................................................................................... 2 Fellowship Director .................................................................................................................................. 3 Faculty ...................................................................................................................................................... 3 Facilities .................................................................................................................................................... 4 Educational Objectives ............................................................................................................................. 4 Curriculum ................................................................................................................................................ 5 Schedule ................................................................................................................................................... 6 Research ................................................................................................................................................... 6
Research Training ............................................................................................................................. 6
Research Projects ............................................................................................................................. 6
Stipend and Benefits ........................................................................................................................ 8
Application Process .................................................................................................................................. 9 Match ....................................................................................................................................................... 9 Further Information................................................................................................................................ 10 Appendix 1: Annual Report ..................................................................................................................... 11 Appendix 2: Faculty Evaluations of Program .......................................................................................... 12 Appendix 3: MIGS Reference Material ................................................................................................... 13 Appendix 4: Surgical Competency List .................................................................................................... 14 Appendix 5: Minimum Case List ............................................................................................................. 17 Appendix 6: Competencies ..................................................................................................................... 18 Consequences of Probation ................................................................................................................... 21 Representations and Warranties ........................................................................................................... 21 Fellowship Acknowledgement and Responsibilities .............................................................................. 21 Institution Agreements and Responsibilities ......................................................................................... 22 Program Director’s Acknowledgements and Responsibilities................................................................ 23 Consent to Release of Information ........................................................................................................ 24 Release of Liability .................................................................................................................................. 24 Preceptor and Institution Agreement .................................................................................................... 25
Page 2 of 25 REQUIREMENTS FOR A POST-GRADUATE FELLOWSHIP IN THE SUBSPECIALTY AREA OF MINIMALLY INVASIVE GYNECOLOGIC SURGERY
Introduction
Fellowship Programs in Minimally Invasive Gynecologic Surgery (FMIGS) are intensive two-year training
endeavors preparing the graduate for advanced minimally invasive gynecologic surgery (MIGS)
expertise. In 2001, the AAGL and the Society for Reproductive Surgeons of the American Society for
Reproductive Medicine (SRS-ASRM) collaborated to oversee the formation of the FMIGS training
programs with a standardized minimum curriculum and a requirement for research. The Council for
Graduate Medical Education does not yet recognize the FMIGS.
Mission Statement
The mission of the FMIGS Board is to provide a uniform training program for gynecologists who have
completed their residency and desire to acquire additional knowledge and surgical skills in minimally
invasive gynecologic surgery (MIGS) so they may: serve as a scholarly and surgical resource for the
community in which they practice; have the ability to care for patients with complex gynecologic surgical
disease via minimally invasive techniques; establish sites that will serve a leadership role in advanced
endoscopic and reproductive surgery; and further research in minimally invasive gynecologic surgery.
Goals
The overall goal of the FMIGS is for the graduate to serve as an independent specialist and consultant in
the surgical management and techniques of advanced benign minimally invasive gynecology surpassing
competence expected at the end of a categorical residency.
Fellowship Training Program
Every program must support the Educational Objectives of FMIGS and in addition may identify specific
areas of concentration within MIGS. An application and a site survey must be completed before
approval.
Approved programs will be reviewed every one to five years. The board may require reevaluation at an
interval of less than one year. If there are any significant changes in the program (e.g. change in the
number of fellow positions, program director, key faculty members, patient volume and procedures;
changes in clinical sites or closure of major research programs), the FMIGS Board must be notified in
writing within 30 days. Each program will be approved for a specific number of fellows. The Board will
review request for additional fellow positions. Every program is required to submit an Annual Report
that includes a list of current faculty, enrolled fellows and the surgical experience and research progress
of each fellow (See Appendix 1).
Performance of a fellowship program will be evaluated on the basis of the:
A) Fellowship director’s written evaluation of the fellow(s)
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B) Fellow(s) completion of required didactic program, as defined by the individual program,
under the auspices of the FMIGS Board
C) Fellow(s) completion of an appropriate scholarly research project and/or contribution
D) Annual evaluation of the training program and fellowship director by the fellows.
E) Annual evaluation of the fellowship training program by the faculty (See Appendix 2)
F) Annual report (See Appendix 1)
G) Site visit report
Fellowship Director
The fellowship director is ultimately responsible for the design and implementation of the fellowship-
training program.
The fellowship director must:
A) Be qualified and experienced in advanced gynecologic endoscopy with a minimum of 5 years
post-residency experience and must be certified by the American Board of Obstetrics and
Gynecology or hold an equivalent certificate from the country in which they reside, if
applicable.
B) Be a member in good standing of the AAGL and/or ASRM and be an active participant in the
AAGL annual meeting.
C) Directly supervise the appropriate education and mentoring of fellows.
D) Ensure that the fellows receive the appropriate clinical instruction and training.
E) Ensure that each fellow in the program undertakes a research project. Research project
does not include a text book chapter, a review article or an educational video.
F) Evaluate the fellow’s progress using multiple evaluators and metrics including competencies
at least every 6 months, meet directly with the fellow to give feedback and assess progress
and goals document and submit evaluation as part of the Annual Report (see Appendix 1).
G) File an Annual Report with the FMIGS Board (see Appendix 1).
H) Provide a timely written response i.e. within 30 days to all concerns expressed at site visit.
The fellowship director must have an identified person with comparable qualification to act in their
behalf if they are not available. The fellowship director may identify a co-director with defined
responsibilities. If the fellowship director or co-director is not able to provide the training, it will be the
responsibility of the sponsoring institution or department to provide the fellow with the required
training.
Faculty
There must be faculty with special interest and expertise related to MIS who participate in the care of
patients and the education of fellows as noted above, ideally faculty have completed MIS fellowship
Page 4 of 25 training or equivalent. It is desirable that the members of the faculty be members of the AAGL and/or
ASRM.
Facilities
1. All new programs must be an integral part of an appropriate academic clinical department with
an accredited residency program and/or meet the criteria established by the FMIGS Board. The
fellowship program must function with the approval, but not necessarily under the direct
supervision, of the department chair in academic settings.
2. The primary hospital facilities must be equipped to provide a state-of-the-art inpatient and
outpatient MIGS experience. Office and ambulatory care facilities must also be appropriately
equipped.
3. Clinical information systems or libraries, and/ or other information systems, including those
relevant to the subspecialty must be readily available for patient care and clinical research at the
host institution.
4. A skills laboratory and/or simulation center must be available for fellowship instruction and
training.
5. The program must have access to laboratory or clinical research facilities (research coordinator,
statistician, etc.) that are adequate in size and appropriately equipped and supervised for fellow
training.
6. Animal, cadaver research and training facilities are desirable.
7. A program may utilize more than one patient–care facility. If more than one site is used, there
must be a Program Letter of Agreement (PLA) with the ancillary site(s), and appropriate faculty
supervision renewed every year.
The Program Letter of Agreement (PLA) must:
A) Identify the faculty who will assume both educational and supervisory responsibilities
for fellows
B) Specify responsibilities of the above faculty for teaching, supervision, and formal
evaluation of fellows
C) Specify the duration and content of the educational experience
D) State the policies and procedures that will govern fellow education during the
assignment.
Educational Objectives
All Educational Objectives are directed toward the standardization of training in minimally invasive
gynecologic surgery. Educational Objectives focus on evidence based medicine, anatomical principles,
Schwartz, S. I. and F. C. Brunicardi (2010). Schwartz's principles of surgery. New York, McGraw-
Hill, Medical Pub. Division.
Traynor, M. P. (2011). Advances in laparoscopy and minimmally invasive surgery. Philadelphia,
Pa., Saunders Co.
Tredwell, R. E. (2010). Ovarian cysts : symptoms, causes, and treatment. New York, Nova
Biomedical Books.
Trivedi, P. H. (2012). Safe and effective gynecological endoscopic and minimal access surgery.
New Delhi, India, Jaypee Brothers Medical Publishers.
Resad P. Pasic, Ronald Leon Levine (2004). A Practical Manual of Hysteroscopy and Endometrial
Ablation Techniques: A Clinical Cookbook. Taylor & Francis Publishers
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Appendix 4: Surgical Competency List
Case Type Understand Understand and Perform
Supplemental Competency
Pre-Fellowship Competency
Laparoscopic Adhesiolysis
Mild/moderate X X
Severe X
Enterolysis X
Laparoscopic Ovarian Surgery
Cystectomy X X
Adnexal detorsion X X
Oophorectomy X X
Ovarian drilling X X
Oophoropexy X
Ovarian cryopreservation X X
Ovarian remnant X
Ovarian transposition X X
Laparoscopic Tubal Surgery
Tubal ligation X
Salpingectomy X X
Salpingoscopy X X
Neosalpingostomy X X
Tubal reanastomosis X X
Paratubal cystectomy X X
Linear Salpingostomy X X
Retroperitoneal Dissection
Ureterolysis X
Uterine artery ligation X
Space of Retzius dissection X X
Presacral neurectomy X
Gastrointestinal and Urinary Procedures
Ureteral stenting X X
Hydrodistension X X
Proctosigmoidoscopy X
Cystoscopy X X
Office-based Endoscopy
Diagnostic hysteroscopy (rigid/flexible) X X
Operative Hysteroscopy X X
Vaginoscopy X
Transvaginal hydrolaparoscopy X
Laparoscopy X
Hysteroscopy
Diagnostic X X
Hysteroscopic Sterilization X X
Pregnancy complications - retained POC X X
Foreign bodies X X
Lysis of synechia - mild, moderate X X
Lysis of synechia – severe X X
Metroplasty X
Polypectomy X X
Myomectomy Type's 0- I - or less than 2cm X X
Myomectomy Type II - or greater than 2cm X
Tubal cannulation X X
Page 15 of 25
Appendix 4: Surgical Competency List
Case Type Understand Understand and Perform
Supplemental Competency
Pre-Fellowship Competency
Endometrial Ablation
Rollerball/endomyometrial resection X
Global endometrial ablation X X
Endometriosis Surgery
Cul de sac dissection X X
Segmental bowel resection and anastomosis X X
Treatment of superficial endometriosis X X
Ureterolysis X
Ureteral reanastomosis X X
Ureteral neocystotomy X X
Bladder surgery for endometriosis X X
Bowel surgery for endometriosis X X
Presacral neurectomy X
Appendectomy X X
Resection of deep infiltrating endometriosis X
Treatment of extra-pelvic sites endometriosis X X
Pelvic Floor Reconstructive Surgery
Paravaginal Repair X
Mesh and conventional for utero-vaginal prolapse X X
Mid-urethral sling X X
Colposuspension X X
Sacrocervicopexy X X
Sacrocolpopexy X X
Sacrocolpoperineopexy X X
Uterosacral suspension X X
Sacrospinous ligament suspension X X
Fistula repair X X
Hysterectomy +/- BSO
Laparoscopic Supracervical Hysterectomy X X
Total Laparoscopic Hysterectomy X
LAVH X X
Trachelectomy X
Vaginal hysterectomy X X
Myomectomy
Laparoscopic myomectomy X
Laparoscopic-assisted myomectomy X
Non-surgical treatment of fibroids X X
Laparoscopic uterine artery occlusion X
Pregnancy Related
Diagnostic/Operative Laparoscopy X X
Laparoscopic cerclage X
Correction of congenital anomalies
Resection of rudimentary uterine horn X
Correction of other lateral and vertical fusion defects X X
Creation of neovagina X X
Repair of specific conditions
Cystotomy X
Enterotomy X
Vascular injury X X
Ureteral injury X X
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Appendix 4: Surgical Competency List
Case Type Understand Understand and Perform
Supplemental Competency
Pre-Fellowship Competency
Oncology Surgery
Omentectomy X X
Pelvic and aortic lymph node dissection X X
Radical Hysterectomy with lymph node dissection X X
Primary or interval debulking for ovarian cancer X X
Imaging
Transvaginal sonography X X
Sonohysterography X X
Intraoperative sonography X X
Hysterosalpingography X X
Transabdominal sonography X X
Pain Management X X
Page 17 of 25 Appendix 5: Minimum Case List
Case Type Minimum Requirement
Hysteroscopic Procedures
Endometrial Ablation 9
Myomectomy 6
Polypectomy, Essure, Lysis of Adhesions, Septum 10
Office-based 10
Laparoscopic Procedures (No more than 25% of these cases can be robotic-assisted.)
Hysterectomy +/- BSO 60 of which 12 have to be either total or supracervical
Myomectomy 10
Adnexal Surgery 30
Retroperitoneal Dissection including ureterolysis 10
Adhesiolysis/enterolysis 20
Endometriosis Stage III and IV 10
Urogynecologic Procedures
Pelvic Floor Reconstructive/Repair Procedures 15
Diagnostic or Operative Cystoscopy 25
Vaginal Hysterectomy 5
Clarification for Minimum Case Numbers is as follows: Cases may be unbundled – for example: Stage 4 endometriosis cases may include several aspects: adnexal surgery as well as retroperitoneal dissection – this type of case can be unbundled. Cases such as Hysterectomy with USO/BSO may not be unbundled. For cases performed in the “Office Setting” – it is not the location, but the manner in which the case is performed to add to the category. For example, Hysteroscopy with Polypectomy performed in the OR, but using only local anesthesia can count towards cases performed in the “Office.” Due to the fact that these numbers represent a minimum number of cases, the Fellow must act as the Primary Surgeon for all of these cases. These are minimum requirements of cases. The Fellow should continue to pursue surgical experience and add to these minimum numbers for the duration of their fellowship.
Page 18 of 25 Appendix 6: Competencies
1. Patient Care
Fellows must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Fellows must demonstrate
competence in:
A) Evaluating a patient's complaint, providing an accurate examination, employing
appropriate diagnostic tests, arriving at a correct diagnosis, and recommending the
appropriate treatment
B) The essential areas of benign gynecology including:
normal physiology of reproductive tract
gynecologic management during pregnancy
gynecologic surgery and complications management
management of critically ill patients
gynecologic pathology
the full range of commonly employed diagnostic procedures, including
ultrasonography, Computed Tomographic (CT) Magnetic Resonance Imaging (MRI)
and other relevant imaging techniques
2. Medical Knowledge
Fellows must demonstrate knowledge of established and evolving medical, clinical,
epidemiological and social-behavioral sciences, as well as the application of this knowledge to
patient care.
Fellows must demonstrate knowledge in:
A) Reproductive health care, diagnosis, management, consultation, and referral
B) The fundamentals of basic science as applied to MIGS
C) Applied surgical anatomy and pathology
D) Basics of risk-benefit analysis, epidemiology, statistics, data collection and management,
and use of medical literature and assessment of its value
3. Practice-based Learning and Improvement
Fellows must demonstrate the ability to investigate and evaluate their care of patients, to
appraise and assimilate scientific evidence, and to continuously improve patient care based on
constant self-evaluation and life-long learning. Fellows are expected to develop skills and habits
to be able to meet the following goals:
A) Identify strengths, deficiencies, and limits in one’s knowledge and expertise
B) Set learning and improvement goals
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C) Identify and perform appropriate learning activities
D) Systematically analyze practice using quality improvement methods, and implement
changes with the goal of practice improvement
E) Incorporate formative evaluation feedback into daily practice
F) Locate, appraise, and assimilate evidence from scientific studies related to their
patient’s health problems
G) Use information technology to optimize learning
H) Participate in the education of patients, families, students, residents and other health
professionals
4. Interpersonal and Communication Skills
Fellows must demonstrate interpersonal and communication skills that result in the effective
exchange of information and collaboration with patients, their families, and health
professionals.
Fellows are expected to:
A) Communicate effectively with patients, families, and the public, as appropriate, across a
broad range of socioeconomic and cultural backgrounds
B) Communicate effectively with physicians, other health professionals, and health related
agencies
C) Work effectively as a member or leader of a health care team or other professional
group
D) Act in a consultative role to other physicians and health professionals;
E) Maintain comprehensive, timely, and legible medical records, if applicable
F) Have the fundamentals of good medical history taking and thoughtful, meticulous
physical examination
5. Professionalism
Fellows must demonstrate a commitment to carrying out professional responsibilities and an
adherence to ethical principles. Fellows are expected to demonstrate:
A) Compassion, integrity, and respect for others
B) Responsiveness to patient needs that supersedes self-interest
C) Respect for patient privacy and autonomy
D) Accountability to patients, society and the profession
E) Sensitivity and responsiveness to a diverse patient population, including but not limited
to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation
F) Ethics and medical jurisprudence
6. Systems-based Practice
Page 20 of 25
Fellows must demonstrate an awareness of and responsiveness to the larger context and system
of health care, as well as the ability to call effectively on other resources in the system to
provide optimal health care.
Fellows are expected to:
A) Work effectively in various health care delivery settings and systems relevant to their
clinical specialty
B) Coordinate patient care within the health care system relevant to their clinical specialty
C) Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or
population-based care as appropriate
D) Advocate for quality patient care and optimal patient care systems
E) Work in inter-professional teams to enhance patient safety and improve patient care
quality
F) Participate in identifying system errors and implementing potential systems solutions
Page 21 of 25 Consequences of Probation
If by the time of your next site review, it is noted that your program is not meeting the Fellowship
standards, as indicated in the Fellowship web page, your program will be automatically placed on one-
year probation. Your online program description will indicate that your site is on probation and all
applicants will be informed. If after the one-year probation the deficiencies are not corrected, we will be
forced to remove your Preceptorship site from the FMIGS program.
Representations and Warranties
By applying for a FMIGS program the program director and institution represent and warrant that:
1. The preceptor(s) will maintain membership in the AAGL and/or the Society of Reproductive
Surgeons.
2. All information submitted by the program director in this application is true to the best of our
knowledge and belief.
3. The program director has the surgical skills and knowledge to be a FMIGS Preceptor.
4. We have received and read a) guidelines of the Endoscopic Surgery Fellowship, b) the
application form of PRECEPTEE, and c) the PRECEPTEE questionnaire.
5. We agree to abide by such Fellowship guidelines, policies, procedures, rules, and regulations as
may be enacted from time to time.
6. The institution and the program director understand and agree that the FMIGS Board of
Trustees may not accept our application for one or more reasons, which do not have to be
justified.
7. We agree to practice medicine according to the professional and ethical standards of our
specialty.
8. We understand and agree that I, as an applicant to become a PRECEPTOR, have the burden of
producing adequate information for proper evaluation of my professional competence,
character, ethics and other qualifications, and for resolving any doubts about such
qualifications. We fully understand that any significant misstatements in or omissions from this
application are cause for denial of appointment to or dismissal from the FMIGS program.
9. The program director realizes that the acceptance by the FMIGS Board of Trustees, as the
program director, does not necessarily qualify him/her to perform certain procedures.
10. The program director has the primary responsibility of the fellow’s training.
Fellowship Acknowledgement and Responsibilities
1. The FMIGS offers a fellowship for applicants accepted by an approved institution.
The Fellowship’s responsibilities include:
a) Providing guidelines for fellowship program.
b) Providing evaluation of potential Fellowship sites.
c) Approval or disapproval of program directors for fellowship training.
d) Providing continuous evaluation of the program director, who will be evaluated not only
by the credentials of the PRECEPTEE accepted for training, but also upon the skill and
Page 22 of 25
knowledge obtained by the PRECEPTEE during training.
e) Providing application forms for PRECEPTEE and Program Director and institution.
f) Providing, as needed, advice and direction to potential or approved PRECEPTEES or
Program directors and/or institutions.
g) Providing a certificate to PRECEPTEE upon completion of his/her training, if approved by
the program director and the Fellowship Board of Trustees.
2. All details of the fellowship are subject to agreement between PRECEPTOR and PRECEPTEE. The
Fellowship disclaims all responsibilities except those specified in the immediately preceding
paragraph.
3. In the performance of all discharge of its obligations pursuant to this Agreement the institution
and program director area at all times acting as an independent contractor engaged in the
profession and practice of medicine. Program Director shall employ his own means and
methods and exercise his own professional judgment in the performance of such services, and
the Fellowship shall have no right of control or direction with respect to such means, methods,
or judgments, or with respect to the details of such services. The sole concern of the Fellowship
under this Agreement or otherwise is that, irrespective of the means selected, such services
shall be provided in a competent, efficient, and satisfactory manner. It is expressly agreed that
the institution and program director shall not for any purpose be deemed to be an employee,
agent, partner, joint venture, ostensible or apparent agent, servant, or borrowed servant of the
Fellowship.
Institution Agreements and Responsibilities
1. If accepted as a FMIGS site, the institution agrees that the Fellowship Board of Trustees may
terminate the continued participation as a Preceptor site if the objectives and terms of the
Fellowship are not being achieved.
2. Institution agrees not to accept any PRECEPTEE who has not completed an approved OB/GYN
residency program and/or who does not have a license (institutional or otherwise) to practice
medicine in my state and country.
3. As a FMIGS site, the institution accepts and assumes the responsibility for the training of the
PRECEPTEE and care of patients involved with the training.
4. As a FMIGS site, the institution further acknowledge that this training program will culminate in
issuance of a certificate of completion of an approved program if the program director
determines that the PRECEPTEE’s performance is satisfactory. However, the certificate or
issuance thereof does not certify that the fellow (1) is a competent surgeon and physician, (2) is
eligible for any other certification, or (3) has any specialized knowledge, skill, and ability.
5. As an approved FMIGS site, the institution here by agrees to indemnify the AAGL and SRS/ASRM
for any claims brought against in connection with the Fellowship. The Fellowship will not be
involved in or bear responsibilities for any claims that might occur as a direct result of patient
care rendered by program director and/or the PRECEPTEE and the institution, or disputes
between the institution or department, the program director or faculty, and the PRECEPTEE.
Page 23 of 25
6. As a FMIGS site, institution reserve the right to terminate a fellowship appointment at any time.
However, I must provide the reason(s) of the termination to the Fellowship Board of Trustees.
7. As a FMIGS site, institution understands and agrees that the PRECEPTEE will be required to
complete an evaluation regarding his/her training experience and that this information will be
submitted to the Fellowship Board of Trustees as privileged information to be used at their
discretion.
8. The institution understands and agrees that it is my duty, as a FMIGS site, to make specific
arrangements with the PRECEPTEE with respect to the duties, responsibilities, liability insurance,
and compensation of the PRECEPTEE.
9. As a PRECEPTOR, I understand and agree that I am responsible of my PRECEPTEE’s training.
10. The institution acknowledges and agrees to maintain workplace standards described in the
AAGL Anti-Harassment Policy, available on the FMIGS website.
Program Director’s Acknowledgements and Responsibilities
1. Once accepted as a program director, I agree that the Fellowship Board of Trustees may
discontinue my being the program director if the objectives and terms of the Fellowship are not
being achieved.
2. I agree to accept no PRECEPTEE who has not completed an approved OB/GYN residency
program and/or who has no license (institutional or otherwise) to practice medicine in my state
and country.
3. I accept the responsibility for the training of the PRECEPTEE and care of patients involved with
the training.
4. I further acknowledge that this training program will culminate in issuance of a certificate of
completion of an approved program if I feel that the PRECEPTEE’s performance has been
satisfactory. However, the certificate or issuance thereof does not certify that the fellow (1) is a
competent surgeon and physician, (2) is eligible for any other certification, or (3) has any
specialized knowledge, skill, and ability.
5. I further acknowledge that the AAGL and SRS/ASRM will not be involved in or bear
responsibilities for any litigation that might occur as a direct result of patient care rendered by
the institution, faculty or PRECEPTEE, or disputes between the institution and/or the faculty
and/or the PRECEPTEE.
6. I reserve the right to terminate a fellowship appointment at any time. However, I must provide
the reason(s) of the termination to the Fellowship Board of Trustees.
7. I understand and agree that my PRECEPTEE will be required to complete an evaluation regarding
his/her training experience and that this information will be submitted to the Fellowship Board
of Trustees as privileged information to be used at their discretion.
8. I understand and agree that it is my duty as PRECEPTOR to make specific arrangements with the
PRECEPTEE with respect to the duties, responsibilities, liability insurance, and compensation of
the PRECEPTEE.
Page 24 of 25
Consent to Release of Information
By applying for appointment (or reappointment) to become a PRECEPTOR, I hereby:
1. signify my willingness to appear for interviews regarding my application;
2. authorize the Fellowship Board of Trustees, AAGL, and SRS/ASRM to consult with
administrators, employees, and members of medical staffs of hospitals, medical schools, or
organizations with which I have been associated with respect to my professional competence,
character, and ethical qualifications;
3. consent to the Fellowship Board of Trustees’, AAGL’s and SRS/ASRM’s inspection of all records
and documents, including, but not limited to, medical records at hospitals, which may be
material to an evaluation of my professional competence and my professional and ethical
qualifications for the FMIGS. If medical records are reviewed, the identity of the patient will be
kept Confidential;
4. authorize the Fellowship Board of Trustees, AAGL, SRS/ASRM, and their representatives to
consult with my past and present professional liability insurance carriers or self-insurance trusts
with respect to professional liability claims involving me;
5. consent to the release of information concerning me by hospitals, medical schools, and
organizations that are requested by the Fellowship Board of Trustees, AAGL and SRS/ASRM to
provide information relevant to the evaluation of my application to become a PRECEPTOR.
Release of Liability
By applying for appointment (or reappointment) both PRECEPTOR and institution, hereby:
1. release from liability AAGL, SRS/ASRM and the Fellowship Board of Trustees, its employees,
agents, and representatives, for any and all of their professional review actions with respect to
the evaluation of my qualifications and appointment to become a PRECEPTOR;
2. release from liability all individuals and organizations who provide to the Fellowship Board of
Trustees and its individual members, AAGL, SRS/ASRM, and their representatives, information
regarding my professional competence, ethics, character, and other qualifications for an
appointment as PRECEPTOR; and
AGREE TO INDEMNIFYAND HOLD HARMLESS THE FELLOWSHIPBOARD OF TRUSTEES,
ITS INDIVIDUAL MEMBERS, AGENTS, EMPLOYEES, REPRESENTATIVES, AND ASSIGNS,
FROM ANYAND ALL LIABILITY FOR DAMAGES INCURRED TO, IN WHOLE OR IN PART,
PERSONS OR PROPERTYARISING (1) FROM THE ACTS OF THE PRECEPTOR OR THE
PRECEPTEE DURING THE COURSE OF THE FELLOWSHIP IN MINIMALLY INVASIVE
GYNECOLOGIC SURGERY, INCLUDING, WITHOUT LIMITATION, LIABILITY FOR
INJURIES TO PATIENTSRESULTING FROM TREATMENTGIVEN BY PRECEPTOR OR
PRECEPTEE, AND/OR (2) PERFORMANCE OF THE RESPONSIBILITIES OF PRECEPTOR OR
PRECEPTEE PURSUANT TO THIS APPLICATION AND AGREEMENT.
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