Joint Provider Continuing Education Credit Application

Click above to save progress and return later. The submission process requires document collection and uploads.

Initial Consultation: Please contact our offices to set up a feasibility consultation prior to completing any online forms. CAMC Institute for Academic Medicine will not perform a review without an executed agreement. There is no charge for this 15-20 minute consultation.

Please email josh.kent@vandalilahealth.org to schedule your consultation.

Submission Deadline: In order to receive consideration for approval for continuing medical education credits, this application should be submitted 120 days prior to the date of the activity. Requests for review after this deadline will not be considered.

Executed Agreement: Before The Institute can begin its formal review process, all potential Joint Providers are required to execute a signed agreement. The agreement outlines the responsibilities and compliance requirements of both parties. The Institute will not move forward with reviewing or approving a joint-providership until this agreement is fully executed.

Joint Providership: The ACCME defines joint providership as the providership of a CME activity by one or more accredited and one or more nonaccredited organizations. Therefore, ACCME accredited providers that plan and present one or more activities with non-ACCME accredited providers are engaging in “joint providership.” Please note: the ACCME does not intend to imply that a joint providership relationship is an actual legal partnership. Therefore, the ACCME does not include the words partnership or partners in its definition of joint providership or description of joint providership requirements. The accredited provider must take responsibility for CE activities.

Company Name

Contact Name

Email

Phone

Program / Conference Title

Date(s)

Location

Participation Type

In PersonVirtual (eg. Teams, Zoom, Live Stream)Hybrid (In Person and Virtual)

Total anticipated number of education hours

*IMPORTANT* For each credit type selected, a Subject Matter Expert or credentialed professional must be a member of the Planning Committee.

Planning Committee Members

You may upload a list of your planning committee members. Please include first name, last name, credentials, and email address.

Please include first name, last name, credentials, and email or upload form below

Planning Committee Members (please include name, credentials, and email address)

Educational Goals Summary

Please provide a short (3-7 sentences) summary of the educational goals of the activity

Needs Assessment

Needs Assessment / Practice Gaps - please indicate need for education and how this was determined

You may upload a Needs Assessment / Determination here

Audience

If you chose "Other Healthcare Professionals" please detail here

Once you've submitted your application, a member of our team will reach out to you and set up an initial planning meeting. If you need immediate assistance, please contact josh.kent@vandaliahealth.org, or mackenzie.lanham@vandaliahealth.or, or jaya.ripley@vandaliahealth.org