CME Provider Application

CME Approval Fees Policy
Updated and Approved at the Board of Directors
Effective Date: January 1, 2016

The Aznma CME Approval Fee is:

  • $175 filing fee
  • $35 for each CME Credit Hour
  • All fees must accompany documentation
  • No Refunds will be given
  • No CME's will be approved in arrears
  • This disclaimer, must be added to your CME form that is provided to the attendees
    • Disclaimer: The speaker/company hereby agrees to protect, indemnify, defend and save the AzNMA, its officers, its employees, and agents harmless from and against any and all claims, demands, actions, damages, loss cost liabilities, expenses and judgments arising out of, or occurring in connection with, any act, omission, negligence, or misconduct on my part of attributable to the speaker. This includes, but is not limited to, misuse of copyrighted material, or any injury or damage that may arise from, or out of, the speaker’s participation at an educational event not sponsored and/or hosted by AzNMA, where AzNMA has approved the CME’s.

Application for Continuing Medical Education Approval

Please complete all spaces on this form. Attach program documentation for verification, and return to the Association's office 8 weeks in advance of the class being offered, this will allow time for advertising.
Please email descriptive materials to director@aznma.org including:

  1.  Specific dates, times, location of course
  2. a tentative schedule of topics and presentations
  3. a brief course description for each presentation
  4. course objectives for each presentation
  5. relevance to medical practice for each presentation
  6. a course flyer, if available
  7. CV and brief bio for each speaker

Disclaimer: The speaker/company hereby agrees to protect, indemnify, defend and save the AzNMA, its officers, its employees, and agents harmless from and against any and all claims, demands, actions, damages, loss cost liabilities, expenses and judgments arising out of, or occurring in connection with, any act, omission, negligence, or misconduct on my part of attributable to the speaker. This includes, but is not limited to, misuse of copyrighted material, or any injury or damage that may arise from, or out of, the speaker’s participation at an educational event not sponsored and/or hosted by AzNMA, where AzNMA has approved the CME’s.

 

APPLICATION FOR CME PROVIDER

 

2-STEP PROCESS

  1.  Please fill out this form as completely as possible. This will allow for approval of CME credit hours at a cost of $175, plus $35/credit hour.  Submit this form at least 8 weeks prior to the course.  Applications submitted after that deadline will be subject to a $75 late-filing fee.
  2. Please call us at 480-921-3088 to make the appropriate payment for the application fees, which is $175.00, plus $35.00 per credit hour.

First name*:
Last name*:
Email*:
Phone*:

Course Title*:
Street Address*:
Address Line 2:
City*:
State*:
Zip*:


Start Date*:
End Date*:
Start Time*:
End Time*:
Is the course 8 weeks or more from today?:
YesNo

Tentative Schedule*:

Brief Description of Course*:

Relevance to Medical Profession*:

Speaker Bios*:

Number of General CME Hours Requested*:
Please enter a number greater than or equal to 0.
General Purpose CME Credit Hours (If none, enter 0)

Number of Pharmaceutical CME Hours Requested*:
Please enter a number greater than or equal to 0.
Pharmaceutical CME Credit Hours (If none, enter 0)

Total CME Hours*:
Please calculate the total CME hours and enter it here.


Upload Speaker CVs:

Upload Course Flyer:

Full Name*:
Street Address*:
Address Line 2:
City*:
State*:
Zip*:

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