Joint Providership Inquiry

Inquiry

Request for Joint Providership
Organization Name:
Does this organization produce, market, re-sell,or distribute health care goods or services consumed by, or used on, patients?*

Yes*No
*If yes, the organization is not eligible to participate in Joint Providership of CME.
Primary contact person:
Email Address
Phone Number

Area Code Phone Number
Describe your organization and its mission:*
Title of Proposed Activity:*
In what state will this meeting be held?*

Street Address

Street Address Line 2

City
Date of Activity:

MonthDay Year
Date
Anticipated Number of CME Credits (hours):
Check the box that best describes the FORMAT of the planned CME Activity:*

1-hour presentation1-day conference with multiple sessions2-3 day conference with multiple sessionsOngoing series of sessions (Tumor Board, CaseConference, etc.)
Describe why you want to offer this educational activity in terms of need and practice gap (i.e. what is the problem, deficiency, or practice issue that you hope this activity will solve?): *
Describe what you hope to accomplish by offering this activity (in terms of change(s) in physician knowledge, competence, behavior or patient outcome). *
Please share anything else you think we need to know about this activity:*
Completion of this document is not a guarantee that the FMA will jointly provide this activity with your organization. FMA staff will contact you within 3 days to discuss the possibility of joint providership with the FMA.
Should be Empty: