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CPE Capstone application submission form:

Please complete Part 1 of the application, and then proceed to Part 2 to upload the required information.

The CCMM Credentials Committee will need this in order to evaluate your application. At any time during this process you can save your progress and resume later.

Upon the initial review, you will then be contacted to pay a $150.00 application fee before your submission is delivered to the Credentials Committee.

If you have any questions, please contact Chris Loscar

CPE Application Part 1

First Name

Last Name

I am a

Organization

Title

Preferred mailing address

Street

City

State

Zip Code

Telephone

Clinical Board Requirements
Must be or have been board certified in a clinical specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association. Must have been in good standing if you chose not to renew board certification.

Board Certified in:

Education Requirements (select A or B below)

A. I have completed 150 hours of management education (116 hours of tested Core courses plus 34 hours of tested Elective management courses through The American Association for Physician Leadership) OR completion of the CPE Four Phase CurriculumB. I have completed an accredited graduate management degree (i.e. MBA, MMM, MS, MHA, MPH, etc.)

Institution

Degree

Date Completed (MM-DD-YYYY)

A copy of graduate degree or transcript

CPE Application Part 2

Please upload the information below. The Credentials Committee will need this information in order to evaluate your application. All of the information below must be uploaded. Documents can be scanned and saved on your computer to be uploaded here.

Medical Training:

A copy of medical school diploma or ECFMG standard certificate.

Licensure:

A copy of current license renewal.

Clinical Practice Experience:

A resume or CV showing three years of clinical practice experience.

Board Certification:

A copy of board certification in a specialty recognized by ABMS or AOA.

Medical Management Experience:

A first person narrative (not to exceed one typed page) describing and attesting to you management experience as noted on the Eligibility page.

A letter of recommendation from candidate's immediate supervisor affirming management experience is required. In the absence of a supervisor, a letter from the CEO of another significant health care organization is acceptable.

Desired Capstone

2018 Fall Capstone - Tampa, FL - November 15th - 18th

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