Joint Providership Request

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About Your Organization

Name *

First

Last

Email *

Phone

Name of Organization *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

About the Activity

Topic/Therapeutic Area to be Addressed in Activity *

Brief overview of Activity *

Is this Activity Commercially Supported? *

Activity Type *

Activity Professional Type *

Uniprofessional
Planned and presented by one profession only

Interprofessional continuing education (IPCE)
An interprofessional team (physician and nurse or nurse and pharmacist, etc.) plans and presents the content to members of the same team

Credit Type *

Physician (AMA PRA Category 1 Credit(s)™)
Registered Nurse (ANCC)
Pharmacist (ACPE)
Physician Assistant (AAPA)
Social Worker (ASWB)
Dietitian (CDR)
Dentist (ADA-CERP)
Psychologist (APA)
Optometrist (COPE)
Family Physician (AAFP)
Nurse Practitioner (AANP)
Certified Case Manager (CCM)

Please select all that apply.

Estimated Number of Credits *

e.g. 0.25, 0.50, 0.75, 1, 2, etc.

Expected Attendance

Anticipated Release Date *

Additional Comments

Medical Learning Institute Inc
40946 US Highway 19N, #602
Tarpon Springs, FL, 34689
888.654.2631 (toll-free)
609.333.1693 (direct)

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