Move the Needle Challenge! Physician MOC Part IV Enrollment Form

Thank you for your committment to quality improvement in the Columbus area! The following form will capture information needed to both enroll you in a CMA ABMS MOC Part IV Portfolio Sponsored QI effort and turned in to ABMS for credit. All fields are required.

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* 1. Unique Board ID

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* 2. Physician Last Name

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* 3. Physician First Name

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* 4. Physician Middle Initial

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* 5. Individual National Provider Identifier (NPI)

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* 6. Email Address

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* 7. Select your Flu Vaccine Quality Improvement Option:

I am a clinician providing flu vaccines and am joining the Move the Needle Challenge to increase my flu vaccination rate 20% from baseline.

I am a clinician not providing flu vaccinations but am joining the Move the Needle Challenge to increase my flu vaccination referral rate 20% from baseline.

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* 8. Start Date

Date / Time

Date

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* 9. Physician Birthday

Date / Time

Date

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* 10. Attestation and Commitment: I agree that by enrolling myself into a CMA Sponsored MOC Part IV Quality Improvement Effort, I will meaningfully participate in designated QI effort calls/webinars/meetings as requested, contribute non-PHI data as requested pertaining to the effort and share improvements within my practice and colleagues. I understand that CMA may share results of this effort and de-identified, non-physician, non-practice-specific data (in the aggregate) with external audiences.

Yes

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* 11. I am a member of the Columbus Medical Association (CMA)

Yes