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:

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* 8. Start Date 

Date

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* 9. Physician Birthday

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.

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

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