Letter of Intent

Letter of Intent for MDS Video Challenge

 

* = required field

NOTE:  Cases that are to be presented at the MDS Video Challenge should not be presented as an abstract in the Poster Areas.

Contact Person:
First Name: *
Last / Family Name:*
Email:*
 
Organization/Group Submitting Video:
Name of Group:*
Address:*
City:*
State / Province:*
Zip / Postal Code:*
Country:*
Email:*
 

Video Submissions

 

Case #1: Title of Case*
Brief summary of case:*
Description of what the video will demonstrate:*
Statement of why the case is unique or of interest: *
Case #2: Title of Case
Brief summary of case:
Description of what the video will demonstrate:
Statement of why the case is unique or of interest:
Case #3: Title of Case
Brief summary of case:
Description of what the video will demonstrate:
Statement of why the case is unique or of interest:


HIPAA Compliant

The author(s) of the Work hereby represents and confirms that he or she has obtained the written consent of any and all patient(s) featured or who are otherwise identifiable or used in the Work to such feature, identification or other use therein and that said consent fully complies with all applicable legal requirements relating to the use of said such patient identifiable material, including, without limitation, if applicable, the specific requirements of the United States Health Insurance Portability and Accountability Act of 1996 ("HIPAA").

Letter of Intent

By submitting this Letter of Intent, you agree to the above and your case(s) will be reviewed by a committee. By the end of May 2019, notifications will be sent out indicating the cases that will be formally considered for review and possible presentation.

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