Claim Your MOC (TEMPLATE)

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NEW! All physicians requesting MOC credit for completing this course must fill out all sections of this form. At this time, the only boards eligible to earn MOC credit from this course are: ABA, ABIM, ABO, ABOHNS, ABP, and ABPath. If you are not certified with one of the named specialty boards, there is nothing more you need to do for completing this course.

Date of Birth (MM/DD/YYYY) *

Please select your specialty board(s): *

Only the boards listed below are eligible for MOC credit for this program. Select all that apply:

American Board of Anesthesiology

American Board of Internal Medicine

American Board of Ophthalmology

American Board of Otolaryngology – Head and Neck Surgery

American Board of Pathology

American Board of Pediatrics

Enter Your ABA Board ID #: *

Enter Your ABIM Board ID #: *

Enter Your ABO Board ID #: *

Enter Your ABOHNS Board ID #: *

Enter Your ABP Board ID #: *

Enter Your ABPath Board ID #: *

Yes, share my participation in this activity with the UTCOM, ACCME, and my specialty board. *

I grant my permission.

* All eligble learners wishing to claim MOC credit for completing this course must also fill out and pass the test following this form. If you do not complete the MOC test, your credit will not be reported.**

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*** All eligble learners wishing to claim MOC credit for completing this course must also fill out and pass the test following this form. If you do not complete the MOC test, your credit will not be reported.

* All eligble learners wishing to claim MOC credit for completing this course must also fill out and pass the test following this form. If you do not complete the MOC test, your credit will not be reported.**