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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 information to evaluate your experience. 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 us at customerservice@physicianleaders.org

CPE Application Part 1

First Name

Last Name

Academic Credential (MBA, MHA, MMM, MS, etc.)

Organization

Title

Career Stage

Preferred mailing address

Street

City

State

Zip Code

Country

Telephone (cell phone)

Desired Capstone

2024 Summer Capstone: September 19-22, 2024

Live Online

2024 Fall Capstone: November 7-10, 2024

Live Online

2025 Winter Capstone: February 6-9, 2025

Live Online

2025 Spring Capstone: April 24-27, 2025

In-Person: Boston, MA

How did you hear about the CPE program?

Name of Colleague:

Name of Organization:

Name of Partner University:

If other, please tell us where you heard about the CPE Program:

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 the CPE prerequisite courses through The American Association for Physician Leadership
B. 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 transcript

Membership Requirements

I understand that having an active AAPL membership is required at the time of attending a CPE Capstone event

I Agree

CPE Application Part 2

Please upload the information below. The Credentials Committee will need this information in order to evaluate your application. All 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:

The CCMM is looking for experiences that document your leadership responsibilities. Each area has a direct relation to the exercises in the Capstone pre-work and when attending the Capstone. Being able to speak to your levels of experience is crucial.

Please provide detailed information regarding the four areas of leadership and 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.

Please note you may want to review and draft your responses separately prior to beginning.

Talent management (direct oversight of other physicians and/or staff, performance evaluations, determining salaries, hiring, and firing of immediate staff).

Data management (what data do you gather and how do you use it)

Fiscal responsibilities (share what your budget oversight and responsibilities are)

Organizational impact (organizational project implementation and stake in the process, managing up the chain, dealing with other stakeholders, etc.). You will be describing 5 of your projects during the Capstone.

Tell us about your future aspirations within physician leadership and how that plus obtaining the CPE designation will help propel you in the future.

A Letter of Recommendation from candidate's immediate supervisor affirming management experience is required. In the absence of a supervisor, another significant health care leader within your organization is acceptable. OR a letter from the CEO of another significant healthcare organization is acceptable as well.

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