CE Request Form - American Diabetes Association

American Diabetes Association73 rd Scientific SessionsJune 21-25, 2013 ● Chicago, ILREQUEST FOR CERTIFICATE/STATEMENT OF CREDITTo receive a Certificate/Statement of Credit, you must complete and fax this request form to the attention ofProfessional Education at 703-253-4358. Should you have any questions, feel free to email us atprofessionaleducation@diabetes.org.Type of CE requesting: _____ Physician________________________________________Physician AssistantPodiatric PhysicianFamily PhysicianNurseNurse PractitionerDietitianPsychologistOther, please list__________________Number of credit hours requesting: _______________________Name: _______________________________________Employer: ____________________________________Mailing Address:____________________________________________________________________City, State, Zip Code: ________________________________________________________________Email to which you would like the certificate sent: ____________________________________________________________________Signature________________________DateAccreditation StatementsPhysiciansThe American Diabetes Association is accredited by the Accreditation Council for Continuing Medical Educationto provide credit for physicians.The American Diabetes Association designates this live activity for a maximum of 33 AMA PRA Category 1Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in theactivity.Family PhysiciansThis Live activity, 73rd Scientific Sessions, with a beginning date of 06/21/2013, has been reviewed and isacceptable for up to 33.00 Elective credit(s) by the American Academy of Family Physicians. Physicians shouldclaim only the credit commensurate with the extent of their participation in the activity.Doctors of OsteopathyCategory 2 credit will be awarded for formal educational programs that are ACCME-accredited or AAFP-approved.

Physician AssistantsAAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Creditfrom organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive amaximum of 33 hours of Category I credit for completing this program.Podiatric PhysiciansThe American Podiatric Medical Association extends affiliate sponsorship to the American Diabetes Associationfor 33 continuing education contact hours (CECHs) for the 73 rd Scientific Sessions to be held on June 21-25, 2013.International PhysiciansThe American Medical Association has determined that physicians not licensed in the US who participate in thisCME activity are eligible for AMA PRA Category 1 credit.European Union of Medical SpecialistsThe European Accreditation Council for Continuing Medical Education (EACCME) and the AmericanMedical Association (AMA) signed an agreement of mutual recognition of CME credits between Europeand the USA whereby: 1) European physicians attending an event in the USA had their credits recognizedin Europe and 2)American physicians attending an event in Europe had their credits recognized in theUSA.The American Diabetes Association designates this educational activity for a maximum of 33 AMA PRA Category1 for the American Diabetes Association’s 73 rd Scientific Sessions. Each medical specialist should claim only thosecredits that he/she actually spent in the educational activity and can be converted by the EACCME into EuropeanCME credits and/ or into National Credits by the European National Authorities.NursesThe American Diabetes Association is accredited as a provider of continuing nursing education by the AmericanNurses Credentialing Center’s COA.California Board of Registered NursingThe American Diabetes Association is also a provider approved by the California Board of Registered Nursing,Provider No. CEP-12196. This activity is approved for 33.0 contact hours.DietitiansThe American Diabetes Association is a Continuing Professional Education (CPE) AccreditedProvider with the Commission on Dietetic Registration (CDR). Registered dietitians (RDs) anddietetic technicians, registered (DTRs) will receive 33.0 continuing professional education units(CPEUs) for completion of this program/material.PsychologistsThe American Diabetes Association is approved by the American Psychological Association to sponsor continuingeducation for psychologists. The American Diabetes Association maintains responsibility for this program and itscontent. This activity offers a maximum of 33.0 hours of continuing education credit. Each psychologist mustattend in their entirety those sessions designated as offered for psychology credit and claim only those hours spentin the educational activity.Certified Diabetes EducatorsTo satisfy the requirement for renewal of certification by continuing education for the National Certification Boardfor Diabetes Educators (NCBDE), continuing education activities must be diabetes related and approved by aprovider on the NCBDE List of Approved Providers (www.ncbde.org). NCBDE does not approve continuingeducation. The American Diabetes Association is on the NCBDE List of Approved Providers.