THE AMERICAN BOARD OF UROLOGY, INC.
2017 RECERTIFICATION EXAMINATION PROCESS
MANDATORY FORMAT FOR PREPARING PRACTICE CASE LOGS
All logs are due March 1, 2017. Courier service is recommended for guaranteed delivery. Logs received after March 15 th must include a $750 late fee.
No logs will be accepted after March 31, 2016. Retain a copy for your records: The Board office disposes of logs after successful completion of
recertification. Your practice log must be six (6) consecutive months in length between August 1, 2015 and January 31, 2017. DO NOT SEND
hospital computer printouts or include diagnosis/procedure codes in Lists 2, 3, and 4. ** If you have been previously deferred due to submission of an
inadequate log you must re-submit your prior log along with your current submission and include all case numbers in your summary.
FOUR SEPARATE lists on 8 1/2 x 11" paper are required. All lists except List 1 must be typed using a font size no smaller than 10-point. A Practice Log
Verification/Notarization Statement for all four lists is attached: It must be signed and your signature must be notarized.
LIST 1: PROCEDURES SUMMARY. One master summary list of procedures performed, including every setting and facility, for which you were the
primary urologist. Complete the attached form. Procedures summarized on this form must reflect all procedures from Lists 3 and 4. Note:
Procedures performed by auxiliary personnel under your supervision must be included. Total the number of cases on the last page.
LIST 2: ADULT LOGS of hospital, ambulatory care facility and office procedures for which you were the primary urologist, listed separately for each
setting and facility, in chronological order.
LIST 3: PEDIATRIC LOGS of hospital, ambulatory care facility and office procedures for which you were the primary urologist, listed separately for each
setting and facility, in chronological order.
Please use the following MANDATORY format for Lists 2 and 3:
At the top of each page: Name of Institution, Your Name, List Number & Name (i.e., Mercy Hospital, John Smith, M.D., List No. 3—Adult Log)
^Case
Number
Patient
Age
Patient
Sex
Date
(Chron. Order)
Diagnosis
(no codes)
Urologic
Procedure
(no codes)
Op/Post-op Morbidity
Complication/Death
Printing the log horizontally will provide more space. If you practice adult or pediatric urology exclusively, only the pertinent list is required.
^Case # refers to the numerical record used by a facility to identify a particular patient (i.e. medical record #, patient #, admission #, hospital #, etc.) Names or
numbers must insure patient anonymity: Social Security Numbers and full names will not be accepted.
LIST 4: COMPLICATIONS NARRATIVES INSTRUCTIONS
The Board is interested in how you approach and manage surgical complications.
1. Report all operative mortalities that you had in the past ten years.
2. Report all complications of Clavien Grade III or higher (see below) from your practice log.
3. Please provide a detailed narrative description of the complication and your management using the
MANDATORY template indicated below. The vast majority of candidates do experience some
complications and provide narratives; however, if it is your intention to claim no complications
considered Grade III or higher on the table below during your practice log period, you are required
to submit a signed notarized, statement to that effect.
4. In your complication narrative, indicate if you obtained any consultations during the care episode
to assist with management of the complication and help with understanding why the complication
occurred?
5. Describe to the board how complications are tracked and/or reported at the hospitals in which you
practice. Do you regularly participate in a morbidity and mortality conference?
6. Does your hospital perform root cause analysis of major adverse events?
COMPLICATIONS NARRATIVE
At the top of each page:
Your name, diplomate number and institution: i.e., John Smith, M.D., #15361, Mercy Hospital
Patient's case #:
Age:
Gender:
Date of procedure:
Diagnosis:
Procedure(s) performed:
Complication:
Clavien Classification:
Narrative: Detailed narrative description of one
or more paragraphs
CLASSIFICATION OF SURGICAL COMPLICATIONS
Definition
Grade I Any deviation from the normal postoperative course without the need for pharmacological
treatment or surgical, endoscopic, and radiological interventions. Allowed therapeutic regimens are: drugs
such as antiemetics, antipyretics, analgesics, diuretics, electrolytes and physiotherapy. This grade also
includes wound infections opened at the bedside.
Grade II Requiring pharmacological treatment with drugs other than such allowed for Grade I
complications. Blood transfusions and total parenteral nutrition are also included.
Grade III Requiring surgical, endoscopic or radiological intervention.
Grade IIIa Intervention not under general anesthesia.
Grade IIIb Intervention under general anesthesia.
Grade IV Life-threatening complication (including CNS complications)* requiring IC/ICU management.
Grade IVa Single organ dysfunction (including dialysis).
Grade IVb Multiorgan dysfunction.
Grade V Death of a patient.
*Brain hemorrhage, ischemic stroke, subarrachnoidal bleeding, but excluding transient ischemic attacks,
CNS, central nervous system; IC, intermediate care; ICU, intensive care unit.
Dindo et al Annals of Surgery- Volume 240, Number 2, August 2004
Send all complications narratives with your notarized Log Verification/Notarization Statement and
completed Practice Breakdown no later than the practice log deadline (courier recommended for
guaranteed delivery) to:
The American Board of Urology
600 Peter Jefferson Parkway, Suite 150
Charlottesville, VA 22911
SAMPLE FORMAT FOR LISTS 2 AND 3:
Following is a sample of what Lists 2 and 3 should look like. Please note that each setting (that is: hospital, ambulatory care/outpatient facility,
and office) should be listed on separate sheets of paper. For example: if you performed procedures on adults at two different hospitals, one
ambulatory care facility and two offices, you will have five different headings on your List 2. If you also performed pediatric procedures, follow
the same format, but label the heading List 3.
Example of procedures performed in a hospital:
General Hospital, Dr. John Smith, List 2-Adult Log, Hospital Procedures
Case #
112233
224455
335577
65
60
45
Age
M
M
F
Sex
Date
6/1/2001
6/4/2001
6/6/2001
Diagnosis
BPH
TCC bladder
Kidney donor
Procedure
TURP
CBF
Left donor nephrectomy
General Hospital Outpatient Clinic, Dr. John Smith, List 2-Adult Log, Ambulatory Care Procedures
Case #
1010101
1020202
1030303
1040404
60
48
35
49
Age
F
M
M
F
Sex
Date
6/1/2001
6/2/2001
6/4/2001
6/4/2001
Diagnosis
Hematuria
Elevated PSA
Kidney Stone
Stress Incontinence
Procedure
Cystoscopy
TRNBx
Lithotripsy
Sling, cystoscopy
Complication or
Morbidity or
Mortality
Complication or
Morbidity or
Mortality
Example of procedures performed in an office:
Urology Associates of Anytown, Inc., Dr. John Smith, List 2-Adult Log, Office Procedures
Case #
JW 11111
SM22121
PT21211
RB31414
65
70
54
67
Age
M
M
F
M
Sex
Date
6/1/2001
6/1/2001
6/1/2001
6/1/2001
Diagnosis
Urinary retention
Incontinence
Bladder calculus
Malignant bladder lesion
Procedure
Uroflow
Needle EMG
Uroflow
Bladder instillation
Complication or
Morbidity or
Mortality
LIST 1: OFFICE, HOSPITAL AND AMBULATORY CARE FACILITY PROCEDURES
FOR SIX MONTHS
Beginning Date:
Ending Date:
Procedures performed by:
#
1
2
3
4
5
6
7
Procedure
LYMPHATIC (as separate procedure)
Lymph node biopsy
Lymphadenectomy, inguinal
Lymphadenectomy, ilioinguinal
Lymphadenectomy, pelvic
Lymphadenectomy, retroperitoneal
Other (LYM) (Detail)
Other (LYM) (Detail)
8
9
10
11
12
13
14
15
16
ABDOMEN
Exploratory laparotomy
Drainage, retroperitoneal abscess
Excision, retroperitoneal tumor/cyst
Herniorrhaphy, over 5 years
Herniorrhaphy, incisional
Closure of evisceration
Other (ABD) (Detail)
Other (ABD) (Detail)
Other (ABD) (Detail)
17
18
19
20
ADRENAL
Adrenalectomy, unilateral
... Bilateral
Other (ADR) (Detail)
Other (ADR) (Detail)
List 1: Procedures Summary
CPT
code
ADULT
OFFICE
HOSPITAL
Number done
AMB. CARE CTR
OFFICE
PEDIATRIC
HOSPITAL
AMB. CARE CTR
38500
38760
38765
38770
38780
38999
49000
49060
49200
49505
49560
49900
49999
60540
60699
1
LIST 1: OFFICE, HOSPITAL AND AMBULATORY CARE FACILITY PROCEDURES
FOR SIX MONTHS
#
Procedure
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
44
43
KIDNEY
Drainage of perineal abscess
Nephrostomy, open
Nephrolithotomy, simple
Nephrolithotomy, staghorn
Pyelolithotomy
Biopsy, needle
Renal Biopsy, open
Nephrectomy, simple, unilateral
... Simple, bilateral
Nephrectomy, radical
Nephroureterectomy
Heminephroureterectomy
Nephrectomy, partial
Renal cyst, unroofing
Harvest of cadaver kidneys
Nephrectomy, donor
Homotransplantation
Autotransplantation
Percutaneous Nephrostomy
Pyeloplasty
Pyeloplasty plus symphysiotomy
ESWL
Renal Ultrasound
Other (KID) (Detail)
45
46
47
48
49
50
URETER
Ureterolithotomy
Ureterectomy (separate procedure)
Ureterolysis
Ureteroureterostomy
Transureteroureterostomy
Ureteroneocystostomy, unilateral
List 1: Procedures Summary
CPT
code
ADULT
OFFICE
HOSPITAL
Number done
AMB. CARE CTR
OFFICE
PEDIATRIC
HOSPITAL
AMB. CARE CTR
50020
50040
50060
50075
50130
50200
50205
50220
50230
50234
50240
50240
50280
50300
50320
50360
50380
50395
50400
50540
50590
76775
50610
50660
50715
50760
50770
50780
2
LIST 1: OFFICE, HOSPITAL AND AMBULATORY CARE FACILITY PROCEDURES
FOR SIX MONTHS
#
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
Procedure
... Bilateral
Ureteroneocystostomy, with bladder flap or
hitch
Ureterosigmoidostomy
Sigmoid conduit, separate procedure
bilateral
Replacement of ureter with bowel
Cutaneous pyelostomy or ureterostomy,
unilateral
... Bilateral
Other (UTR) (Detail)
Other (UTR) (Detail)
Other (UTR) (Detail)
Other (UTR) (Detail)
BLADDER
Repair of enterovesical fistula
Cystostomy, trocar
Cystostomy, open
Cystolithotomy
Excision urachal cyst or tumor
Diverticulectomy
Partial cystectomy
Partial cystectomy, with
ureteroneocystostomy
Simple cystectomy complete
Simple cystectomy with cutaneous
ureterostomy
Radical cystectomy with
ureterosigmoidostomy
Simple cystectomy with ileal conduit
Radical cystectomy with ileal conduit
Radical cystectomy with continent diversion
List 1: Procedures Summary
CPT
code
ADULT
OFFICE
HOSPITAL
Number done
AMB. CARE CTR
OFFICE
PEDIATRIC
HOSPITAL
AMB. CARE CTR
50785
50810
50815
50840
50860
53899
44660
51010
51040
51050
51500
51525
51550
51565
51570
51580
51585
51590
51595
51596
3
LIST 1: OFFICE, HOSPITAL AND AMBULATORY CARE FACILITY PROCEDURES
FOR SIX MONTHS
CPT
code
76
77
78
79
80
81
82
83
84
85
Procedure
Pelvic exenteration with male urinary
diversion
Bladder instillation
Cystometrics
Complex cystometrogram
Uroflowmetrics
Needle EMG
Voiding pressure studies
Intra-abdominal voiding pressure
Vesical neck plasty
Urethropexy (Marshall-Marchetti)
86
87
88
Abdomino-vaginal vesical neck suspension,
with or without endoscopic control (e.g.,
51845
Stamey, Raz, modified Pereyra)
Repair of rupture
51860
Cystostomy, closure
51880
#
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
Repair of vesicovaginal fistula (abdominal)
Repair of exstrophy, initial
Enterocystoplasty
Vesicostomy
Bladder biopsy
Bladder Tumor Fulgeration
Cystourethroscopy with removal of calculus
Cystourethroscopy with lithotripsy
Urethroplasty with tubularization of
posterior urethra and/or lower bladder, for
incontinence
Dilation of urethral stricture
Anterior colporrhaphy
Combined anteroposterior colporrhaphy
Sling operation for stress incontinence
Repair of vesicovaginal fistula (vaginal)
Other (BLA) (Detail)
List 1: Procedures Summary
ADULT
OFFICE
HOSPITAL
Number done
AMB. CARE CTR
OFFICE
PEDIATRIC
HOSPITAL
AMB. CARE CTR
51597
51720
51725
51726
51741
51785
51795
51797
51800
51840
51900
51940
51960
51980
52204
52224
52352
52353
53443
53620
57240
57260
57288
57320
53899
4
LIST 1: OFFICE, HOSPITAL AND AMBULATORY CARE FACILITY PROCEDURES
FOR SIX MONTHS
Procedure
#
104 Other (BLA) (Detail)
105 Other (BLA) (Detail)
106 Ultrasound of Bladder (PVR)
PROSTATE
107 Needle Bx Prostate
108 Prostatectomy, perineal, radical
Prostatectomy, perineal, radical plus pelvic
109 lymphadenectomy
110 Prostatectomy, suprapubic
111 Prostatectomy, retropubic, simple
112 Prostatectomy, retropubic, radical
Prostatectomy, retropubic, radical plus
113 pelvic lymphadenectomy
114 Open insertion of radioactive materials
... Percutaneous insertion of radioactive
115 materials
116 Other (PRO) (Detail)
117 Other (PRO) (Detail)
118 Other (PRO) (Detail)
URETHRA
119 Closure, urethro-rectal fistula
Urethrostomy, external (separate
120 procedure)
121 Urethrostomy, perineal
122 Meatotomy
123 Incise and drain periurethral abscess
124 Biopsy of urethra
125 Urethrectomy, separate procedure
126 Diverticulectomy (female)
127 Diverticulectomy (male)
128 Excision of urethral prolapse
129 Urethroplasty for anterior stricture
List 1: Procedures Summary
CPT
code
ADULT
OFFICE
HOSPITAL
Number done
AMB. CARE CTR
OFFICE
PEDIATRIC
HOSPITAL
AMB. CARE CTR
76856
55700
55810
55815
55821
55831
55840
55845
55860
55899
45820
53000
53010
53020
53040
53200
53215
53230
53235
53275
53400
5
LIST 1: OFFICE, HOSPITAL AND AMBULATORY CARE FACILITY PROCEDURES
FOR SIX MONTHS
Procedure
#
130 ... Staged
Urethroplasty for anterior stricture, one
131 stage
132 Transpubic repair membranous stricture
133 ... Perineal
134 Reconstruction for incontinence
135 Prosthesis for incontinence
136 Meatoplasty
137 Repair, urethral injury
138 Fistula repair
139 Urethral dilation male sound first
140 Urethral dilation female
Straightening of chordee with or without
141 mobilization of urethra
Chordee correction for first stage
142 hypospadias repair
143 Magpi/Mathieu
144 Major urethroplasty
145 Penoscrotal hypospadias
146 Repair of epispadias
147 Repair of epispadias with incontinence
148 Closure, urethro-vaginal fistula
149 Other (UTA) (Detail)
150 Other (UTA) (Detail)
151
152
153
154
155
PENIS
Revascularization (microsurgery)
Meatotomy: Infant
Destruction of lesion, penis
Laser destruction, lesion penis
Surgical excision, lesion penis
List 1: Procedures Summary
CPT
code
53405
ADULT
OFFICE
HOSPITAL
Number done
AMB. CARE CTR
OFFICE
PEDIATRIC
HOSPITAL
AMB. CARE CTR
53410
53415
53440
53445
53450
53505
53520
53600
53660
54300
54304
54322
54328
54332
54380
54385
57310
53899
37788
53025
54050
54057
54060
6
LIST 1: OFFICE, HOSPITAL AND AMBULATORY CARE FACILITY PROCEDURES
FOR SIX MONTHS
#
156
157
158
159
160
161
162
163
164
165
166
167
Procedure
Destruction of lesion(s), penis (e.g.,
condyloma papilloma, molluscum,
contagiosum, herpetic vesicle), extensive,
any method
Biopsy, penis
Amputation, partial
Amputation, complete
Amputation plus ilioinguinal
(inguinofemoral) lymphadenectomy
Circumcision, Newborn using clamp
Circumcision
Rigidity test
Correction of chordee without hypospadias
Insertion of penile prosthesis, non-inflatable
Insertion of inflatable penile prosthesis
Shunt, cavernosum to saphenous vein
168 Shunt, cavernosum to spongiosum, open
Shunt, cavernosum to spongiosum,
169 percutaneous
170 Repair of major injury
171 Drainage, scrotal wall abcess
172 Other (PEN) (Detail)
173 Other (PEN) (Detail)
174 Other (PEN) (Detail)
175
176
177
178
179
180
181
182
TESTIS
Biopsy, testis
Excision lesion of testis
Orchiectomy, simple, unilateral
... Bilateral
Orchiectomy, inguinal (radical)
Reduction plus fixation, torsion
Orchiopexy, unilateral
... Bilateral
List 1: Procedures Summary
CPT
code
ADULT
OFFICE
HOSPITAL
Number done
AMB. CARE CTR
OFFICE
PEDIATRIC
HOSPITAL
AMB. CARE CTR
54065
54100
54120
54125
54130
54150
54161
54250
54304
54400
54405
54420
54430
54435
54440
55100
55899
54505
54510
54520
54530
54600
54640
7
LIST 1: OFFICE, HOSPITAL AND AMBULATORY CARE FACILITY PROCEDURES
FOR SIX MONTHS
CPT
code
54660
54670
55400
55300
55899
#
183
184
185
186
187
188
Procedure
Insertion testicular prosthesis
Repair testis (trauma)
Vasovasostomy
Vasotomy for vasogram plus biopsy
Other (TES) (Detail)
Other (TES) (Detail)
189
190
191
192
193
194
195
196
EPIDIDYMIS AND SPERMATIC CORD
Biopsy epididymis
Excision lesion epididymis
Excision spermatocele
Epididymectomy, unilateral
Epididymovasostomy, unilateral
Ligation internal spermatic vein
Other (EPI) (Detail)
Other (EPI) (Detail)
54800
54830
54840
54860
54900
55530
55899
197
198
199
200
201
202
203
SCROTUM
Hydrocelectomy
Incise and drain abscess
Resection of scrotum
Repair scrotum (trauma)
Vasectomy
Other (SCR) (Detail)
Other (SCR) (Detail)
55040
55100
55150
55175
55250
55899
204
205
206
207
ENDOSCOPY
Percutaneous nephroscopy with calculus
removal or lithotripsy up to 2 cm
... Over 2 cm
Percutaneous nephroscopy
Percutaneous endopyeloplasty
List 1: Procedures Summary
ADULT
OFFICE
HOSPITAL
Number done
AMB. CARE CTR
OFFICE
PEDIATRIC
HOSPITAL
AMB. CARE CTR
50080
50081
50551
50575
8
LIST 1: OFFICE, HOSPITAL AND AMBULATORY CARE FACILITY PROCEDURES
FOR SIX MONTHS
#
208
209
210
211
212
213
Procedure
Endoscopic injection of implant material
into the submucosal tissue of the urethra
and/or bladder neck
Cystoscopy
Cystoscopy plus ureteral catheterization
ureter and/or renal pelvis
Cystoscopy plus cup biopsy, bladder
Cystoscopy and fulguration
Cystoscopy, TUR bladder tumor(s) (<2 cm)
... Medium bladder tumor(s) (2 - 5 cm)
... Large bladder tumor(s)
Cystoscopy, hydrodilation of bladder
Cystourethroscopy with direct vision
218 internal urethrotomy
Cystoscopy, calibration and dilation,
219 stricture
214
215
216
217
220
221
222
223
224
Cystourethroscopy with removal of foreign
body, calculus or ureteral stent from urethra
or bladder (separate procedure) simple
... Complicated
Litholapaxy; crushing or fragmentation of
calculus by any means in bladder and
removal of fragments simple, small <2.5
cm
... Large or complicated >2.5 cm
Cystoscopy, extraction ureteral calculus
225 Cystoscopy with placement of ureteral stent
Cystourethroscopy, with ureteroscopy
and/or pyeloscopy (includes dilation of the
ureter and/or pyeloureteral junction by any
226 method)
List 1: Procedures Summary
CPT
code
ADULT
OFFICE
HOSPITAL
Number done
AMB. CARE CTR
OFFICE
PEDIATRIC
HOSPITAL
AMB. CARE CTR
51715
52000
52005
52007
52204
52224
52234
52235
52240
52260
52276
52281
52310
52315
52317
52318
52320
52332
52351
9
LIST 1: OFFICE, HOSPITAL AND AMBULATORY CARE FACILITY PROCEDURES
FOR SIX MONTHS
Procedure
#
227 Ureteroscopy with biopsy or fulguration
228 Ureteroscopy with resection of tumor
229
230
231
232
233
234
235
236
237
238
239
240
241
242
Cystourethroscopy, with incision,
fulguration, or resection of bladder neck
and/or posterior urethra (congenital valves,
obstructive hypertrophic mucosal folds)
Transurethral incision of prostate
TUR bladder neck
Transurethral resection of prostate
TUR for regrowth of obstructive tissue
longer than one year post-operative
Laser prostatectomy - coagulation
Laser prostatectomy - vaporization
Other (ENDO) (Detail)
Other (ENDO) (Detail)
Other (ENDO) (Detail)
Other (ENDO) (Detail)
Other (ENDO) (Detail)
Other (ENDO) (Detail)
Other (ENDO) (Detail)
LAPAROSCOPY
243 Laparoscopy, diagnostic
244 Laparoscopic lymphadenectomy/pelvic
Laparoscopic
lymphadenectomy/retroperitoneal, single or
245 multiple
CPT
code
52354
52355
OFFICE
HOSPITAL
Number done
AMB. CARE CTR
OFFICE
PEDIATRIC
HOSPITAL
AMB. CARE CTR
52400
52450
52500
52601
52630
52647
52648
53899
49320
38571
38570
Laparoscopic
246 lymphadenectomy/retroperitoneal, bilateral
247 Laparoscopic repair of inguinal hernia
38571
49650
248 Laparoscopic ligation of spermatic vessels
55550
List 1: Procedures Summary
ADULT
10
LIST 1: OFFICE, HOSPITAL AND AMBULATORY CARE FACILITY PROCEDURES
FOR SIX MONTHS
Procedure
#
249 Laparoscopic nephrectomy
256
257
258
259
Laparoscopic orchiopexy, first or one stage
... Second stage
Laparoscopy, adrenalectomy
Laparoscopy, partial nephrectomy
Laparoscopy, nephroureterectomy
Laparoscopy, prostatectomy
Laparoscopy, destruction of renal lesion
(e.g. cryotherapy)
Laparoscopy, other (Detail)
Laparoscopy, other (Detail)
Laparoscopy, other (Detail)
260
261
262
263
264
265
266
OFFICE VISITS
New patient
Established patient
Normal newborn
Consultation
Outpatient visit-established
Outpatient visit-new patient
Prolonged services
250
251
252
253
254
255
CPT
code
50545
ADULT
OFFICE
HOSPITAL
Number done
AMB. CARE CTR
OFFICE
PEDIATRIC
HOSPITAL
AMB. CARE CTR
54699
54699
60650
50546
50548
50541
53899
99201
99211
99432
99271
99211
99201
99354
TOTAL OF ALL PROCEDURES
List 1: Procedures Summary
11
AMERICAN BOARD OF UROLOGY
PRACTICE LOG VERIFICATION STATEMENT
Name________________________________________________________________________________________
Medical School: _______________________________________________________________________________
Urology Residency Training Program:______________________________________________________________
Please indicate if you have an area of special focus in your practice (select one):
__ General
__ Andrology
__ Endourology
__ Female
__ Infertility
__ Oncology
__ Pediatric
__ Urolithiasis
If you have had fellowship training, please state the subspecialty area, where and when the fellowship was done:
_____________________________________________________________________________________________
Please describe your current practice in 100 words or less:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
The electronic log submission and documentation represent a true, complete, and accurate log of my consecutive
office visits and surgical procedures for the required time period.
Candidate: __________________________________________ Office Phone: _____________________________
Signature
Office Fax: _______________________________
(Signature must be notarized)
Your signature on the Practice Log Verification Statement attests that you have reviewed the data
contained in your log submission and that it is a true, complete, and accurate log of your consecutive
office visits and surgical procedures for the required time period. If, following review by the ABU
Committee charged with reviewing logs, it becomes necessary to repeat processing on a log submission
due to errors, oversights, or omissions, a $500 fee will be assessed for this process.
Notary: