Administrator CME
Program
Institute for Medical Quality
180 Howard Street, Suite 210
San Francisco, CA 94105
Name of Prospective CME Provider Organization
Address
City, State, Zip
Website Address:
Re: Intent to Apply for CME Accreditation
Dear IMQ,
This letter states my organizations interest in becoming an accredited
Continuing Medical Education (CME) provider. The following best describes our
organization:
1. Type of organization: Please check the category that most accurately describes
your organization and provide details related to the category you select.
__Hospital/Health Care Delivery System (name of the system):
__ Medical Group
__Non Profit Physician Membership Organization (specialty society)
__Other Non Profit Organization (please specify):
__Insurance Company or Manage Care Company
__Publishing/Education Company
__For profit (please specify):
__Government or Military
__Other or not classified (please specify):
2. Is your organization: ___ for-profit or ___ non-profit? Please state the tax
classification for your organization:
3 . The ACCME defines a commercial interest as any entity producing, marketing,
producing, marketing, re-selling or distributing health care goods or services
consumed by, or used on, patients. A commercial interest is not eligible for
accreditation. The ACCME does not consider providers of clinical service
directly to patients to be commercial interests. To be considered as a
candidate for accreditation you must attest to the following by checking each
statement:
__We are not a commercial interest under the ACCME definition.
__We do not have a parent organization or any sister organization(s) that is a
commercial interest under the ACCME definition.
4. Briefly describe your plans for your CME program in terms of the:
a. Physician learners you are targeting for your educational activities:
b. Types and frequencies of CME activities you intend to conduct:
1
c. Percent of physician learners you estimate will be from within the state of
California and/or neighboring states including Alaska and Hawaii? ___%
5. Identify your Primary CME Contact:
a. Name:
b. Phone:
c. Email address:
Signature
Name
Chief Executive Officer or Executive Director
Date