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<form method="post">
  <input type="hidden" name="UserId" value="57409">
  <div class="card border-0 min-vh-100" id="fellowship">
    <div class="card-body pt-4">
      <p> Dr. Heiwon Chung Whang is applying for the <strong>FPD - Adult Complex Thyroid and Parathyroid Surgery (ACTPS) Exam</strong>. Listed below is your information as it was provided to the ABS by Dr. Chung Whang. </p>
      <ul class="list-group list-group-flush">
        <li class="list-group-item ps-0 border-0"><strong>Authenticating Official:</strong> Michael Pasquale, MD</li>
        <li class="list-group-item ps-0 border-0"><strong>Authenticating Official Email:</strong> Michael.Pasquale@lvhn.org</li>
        <li class="list-group-item ps-0 border-0"><strong>Institution:</strong> Lehigh Valley Hospital</li>
      </ul>
      <div class="mt-3">
        <p>This is the statement electronically signed by Dr. Chung Whang giving the ABS permission to request a reference from you regarding their complex thyroid/parathyroid surgery practice</p>
      </div>
      <input type="hidden" name="AttestationResponses[0].ExamAttestationResponseId" value="6">
      <input type="hidden" name="AttestationResponses[0].ExamUserReferenceLetterId" value="190">
      <div class="mt-3 small bg-light-subtle p-3 border"> I hereby authorize any hospital or medical staff where I now have, have had, or have applied for medical staff privileges, and any medical organizations of which I am a member or to which I
        have applied for membership, and any person who may have information (including medical records, patient records, and reports of committees) which is deemed by ABS to be material to its evaluation of this application, to provide such
        information to representatives of the ABS. I agree that communications of any nature made to the ABS regarding this application may be made in confidence and shall not be made available to me under any circumstances. I hereby release from
        liability any hospital, medical staff, medical organization or person, and ABS and its representatives, for acts performed in connection with this application. I authorize the ABS to transmit a reference form request electronically to the
        above-named physician at the email address above and affirm that it ultimately remains my responsibility to ensure these forms are completed. </div>
      <div class="mt-3"> I certify that Dr. Chung Whang practiced complex thyroid/parathyroid surgery at Lehigh Valley Hospital between 11/01/2021 and 10/30/2024, and I support their application for focused practice designation in ACTPS. </div>
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                <input type="radio" class="form-check-input" value="true" id="Yes_" name="AttestationResponses[0].Response">
              </div>
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            <label class="form-control" for="Yes_">Yes</label>
          </div>
        </div>
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                <input type="radio" class="form-check-input" id="No_" name="AttestationResponses[0].Response" value="false">
              </div>
            </div>
            <label class="form-control" for="No_">No</label>
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        </div>
        <div class="col-md-12">
          <textarea class="form-control shadow-sm" name="AttestationResponses[0].ResponseExplanation" placeholder="If you answered 'No,' please provide an explanation." rows="4"></textarea>
          <div asp-validation-for="AttestationResponses[0].ResponseExplanation" class="text-danger small"></div>
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      <input type="hidden" name="AttestationResponses[1].ExamAttestationResponseId" value="7">
      <input type="hidden" name="AttestationResponses[1].ExamUserReferenceLetterId" value="190">
      <div class="mt-3"> By checking the box below, I agree to sign this form by electronic means. My electronic signature is the legal equivalent of a handwritten signature and can be enforced in the same way. </div>
      <div class="col-md-12 my-3">
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              <input type="checkbox" class="form-check-input" name="AttestationResponses[1].Response" id="Checkbox_" value="true">
            </div>
          </div>
          <label class="form-control" for="Checkbox_"> I attest that my response is truthful and complete to the best of my knowledge. </label>
        </div>
        <span class="text-danger small field-validation-valid" data-valmsg-for="AttestationResponses[1].Response" data-valmsg-replace="true"></span>
      </div>
    </div>
    <div class="card-footer">
      <div class="row">
        <div class="col-md-4">
          <input type="submit" class="btn btn-success col-12" name="btnSave" value="Save Attestation">
        </div>
      </div>
    </div>
  </div>
  <input name="__RequestVerificationToken" type="hidden" value="CfDJ8J0SwadI-NVMkS9bYQFBGNPURgwnFw64T3-J2m35O-LGOIyItSxMJvVpshpCMJWJOyIDK6g1P-so_pNv8GFojaIQhXcP0USYnjfjRxIa2hngCLdlU5sgCJwX9up-t0AfIRKYVrsaKUs6Yr26Nkm6JZA">
</form>

Text Content

Dr. Heiwon Chung Whang is applying for the FPD - Adult Complex Thyroid and
Parathyroid Surgery (ACTPS) Exam. Listed below is your information as it was
provided to the ABS by Dr. Chung Whang.

 * Authenticating Official: Michael Pasquale, MD
 * Authenticating Official Email: Michael.Pasquale@lvhn.org
 * Institution: Lehigh Valley Hospital

This is the statement electronically signed by Dr. Chung Whang giving the ABS
permission to request a reference from you regarding their complex
thyroid/parathyroid surgery practice

I hereby authorize any hospital or medical staff where I now have, have had, or
have applied for medical staff privileges, and any medical organizations of
which I am a member or to which I have applied for membership, and any person
who may have information (including medical records, patient records, and
reports of committees) which is deemed by ABS to be material to its evaluation
of this application, to provide such information to representatives of the ABS.
I agree that communications of any nature made to the ABS regarding this
application may be made in confidence and shall not be made available to me
under any circumstances. I hereby release from liability any hospital, medical
staff, medical organization or person, and ABS and its representatives, for acts
performed in connection with this application. I authorize the ABS to transmit a
reference form request electronically to the above-named physician at the email
address above and affirm that it ultimately remains my responsibility to ensure
these forms are completed.
I certify that Dr. Chung Whang practiced complex thyroid/parathyroid surgery at
Lehigh Valley Hospital between 11/01/2021 and 10/30/2024, and I support their
application for focused practice designation in ACTPS.

Yes

No


By checking the box below, I agree to sign this form by electronic means. My
electronic signature is the legal equivalent of a handwritten signature and can
be enforced in the same way.

I attest that my response is truthful and complete to the best of my knowledge.