Total Member Involvement Collaboration For Wellness - April 12 - May 4, 2020

Credit Request Form

The AMA recommends that the accredited provider document “the actual number of credits earned by individual physician participants.” This documentation is also required for other professions. In
order to comply with these requirements, please complete this form and indicate the number of hours attended. The actual hours are indicated next to the session for each profession.

Please complete the form below in order to provide you with the correct number of credit hours:

Name: _________________________________________________________ _______ Specialty: _________________________________

(Please Print Legibly) Degree
Mailing Address: _________________________________________________ (H)  or (O) 

City: ________________________________________ State: ____ Zip Code: _______________

Phone: _____________________________ Email: _______________________________________

Indicate the area of your professional practice:  Medicine  Administration  Other _____________
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Date Time Lecture Credits

April 12, 2020 5:00 PM – 7:00 PM Patient Safety and Service Quality  2.0

April 13, 2020 12:00 PM – 1:00 PM Total Person Wellness Part 1  1.0

April 19, 2020 5:00 PM – 7:00 PM Urban and Rural Issues in Planning and Service Delivery  2.0

April 20, 2020 12:00 PM – 1:00 PM Total Person Wellness Part II  1.0

April 26, 2020 5:00 PM – 7:00 PM Cultural Competence  2.0

April 27, 2020 12:00 PM – 1:00 PM Total Person Wellness Part III  1.0

May 03, 2020 5:00 PM – 7:00 PM Making Urgent Care Effective & Efficient for Everyone  2.0

May 04, 2020 12:00 PM – 1:00 PM Total Person Wellness Part IV  1.0

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This activity is designated for a maximum of 12 AMA PRA Category 1 Credit(s)™ Total hours Attended: ______

I certify that I attended the session(s) specified above for this activity.

Signature: _____________________________________________________________________