Massachusetts Medical Society: Initial Application for Joint Providership

Initial Application for Joint Providership

Please complete the Initial Application below to have an education activity considered for joint providership by the Massachusetts Medical Society (MMS). Please note that a separate application is required for each activity.

Your application will be reviewed within 1-2 weeks of its receipt at MMS. You may be contacted for additional information. If your initial application is accepted, you will be informed of the associated joint providership fee and provided the MMS CME Activity Planning Document and related materials for completion and submission to the MMS Committee on Continuing Education Review.

Please direct any questions about MMS Joint Providership to Ms. Liza Martin, Manager, Joint Providership Program at lmartin@mms.org or (781) 434-7301.

Applicant Information:

1.  Name of organization* 

2.  Contact person* 

3.  Address* 

4.  Email* 

5.  Telephone number* 

Activity Information:

6.  Title of activity*   

7.  Activity format (i.e. live event, webinar, online course, home study)* 

8.  Date of live activity or launch date of online course* 

9.  If live activity, length of event (number of days) 

10.  If live activity, start and end times for each date   

11.  If live event, number of faculty members (including moderators, panelists, and facilitators) 

12.  Briefly describe the learning methods to be used (i.e., lecture, case study, panel discussion, breakout sessions, etc.)*   

13. What revenue sources will pay for the expenses of the activity?

 14.  Number of commercial supporters expected to be contacted for financial support of the activity (if none, write 0)*   

15.  This activity promotes improvement or quality in health care and was planned free of commercial interest.*  

                                      

16.  What are the professional practice gaps that this activity will address?* 

17.  Give a brief (~200 words) general description of the planned activity.*   

18.  Why are you seeking joint providership with the MMS for this educational activity?* 

To submit your application, click on the "submit form" button below.  If you have any questions, contact the MMS Department of Continuing Education & Certification at mmscmecertification@mms.org or 800-322-2303, x7306. 

                                                                  

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