Request Access
|
LOGIN
About
Data Use
Participating Sites
FAQs
QCDR
Sign Up
Renew
Donate
Contact
Renew Your Existing Account
This form is for
EXISTING
accounts only.
If this is a new account, please click on the Sign Up tab.
Please note our new mailing address:
Endocrine Surgery Quality Foundation
838 E High St, # 140
Lexington, KY 40502
US Programs
$200 Administrative fee per program
$1300 for one physician, $2300 for two physicians with a $2800 maximum at an program for 3 or more physicians
International Programs
$200 Administrative fee per program
$1000 per year per site
Name
*
First
Last
Are you based in the United States?
*
Yes
No
Phone
*
Phone (International)
*
Email Address
*
Name of Program or Primary Institution
*
Name of CESQIP Physician Champion at your site?
*
First
Last
Physician Champion phone
*
Physician Champion phone (Int'l)
*
Physician Champion email
*
Name of CESQIP Administrative Champion at your site?
*
First
Last
Administrative Champion phone
*
Admin. Champion phone (Int'l)
*
Administrative Champion email
*
In how many new facilities (if any) do your program’s surgeons perform endocrine surgery procedures?
*
0
1
2
3
4
5
6
7
8
9
Please list the name(s) of each new facility/hospital in your program
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Please list all CESQIP participants at your program
*
Participant Name
Email Address
Please include surgeons, administrators, fellows, etc.
To add another participant, click the (+) button.
Please be accurate, as non-listed accounts will be de-activated.
I would like to pay by
*
Online by credit card (convenience fee applies)
Mail a check
I am a member of Latin American CESQIP (no payment due)
Total Number of Physicians In Program
*
$1,300 - One Physician
$2,300 - Two Physicians
$2,800 - Three or More Physicians
Please list the total number of physicians in your program, across all sites.
Total Number of Physicians In Program
*
$1,300 - One Physician
$1,300 - Two Physicians
$1,300 - Three or More Physicians
Please list the total number of physicians in your program, across all sites.
Total Number of Physicians In Program
*
One Physician
Two Physicians
Three or More Physicians
Please list the total number of physicians in your program, across all sites.
Annual Administrative Fee
*
Price:
$200.00
DUA Fee:
Subtotal:
Subtotal:
Credit Card Convenience Fee
*
Price:
$0.00
Credit Card Convenience Fee
*
Price:
$0.00
Total (including credit card convenience fee)
$0.00
Total
$0.00
Credit Card
*
Discover
MasterCard
Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Expiration Date
Security Code
Cardholder Name
