Clinical Preceptor CME Claim Form
Submit your claim for continuing medical education as a clinical preceptor. Please complete all fields accurately.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Professional Title/Role
*
Institution or Affiliation
*
CME Activity Title
*
Date of CME Activity
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of CME Hours Claimed
*
Brief Description of Preceptor Activity
*
Upload Supporting Documentation (if required)
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