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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
Preferred mailing address

 

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.
 
 
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:

Licensure:

Clinical Practice Experience:

Board Certification:

Medical Management Experience:
  • The CCMM is looking for experiences that document your leadership responsibilities. For example: making physician hiring decisions, rather than simply interviewing prospective physicians, or chairing a committee, rather than simply serving on a committee.
  • Please provide detailed information regarding the four areas of leadership/ managerial experience as noted below.
  • Be sure to mention your role and dates when you had oversight in that specific area.
  • In the case you cannot attest to oversight in any specific area, please explain why or elaborate as much as possible.