Verification of Participation & Certificate Request 28 th Annual Congress Phoenix, Arizona November 6 9, 2014
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1 Complete this form in its entirety to claim the credits commensurate with your participation at the ACP s 28 th Annual Congress. You can only claim credit for one session if it runs concurrently with others. ACP staff will calculate your credit total and fill in the hours for which you participated. Note that the maximum credits awarded for participation at the 28 th Annual Congress are as follows: 29 AMA PRA Category 1 Credits TM ; 29 AOA Category 2-A credits; 29 SVU-CMEs; nursing contact hours. Note that all new or reprint certificate requests received after Friday, January 30, 2015 will be considered on a caseby-case basis and are subject to an administrative processing fee of $ Please submit the completed form to the ACP headquarters by (education@acpmail.org) or fax ( ). PARTICIPANT INFORMATION Full Name (including degree/designation) License # (nurses ONLY) Address Telephone RTIFICATE REQUEST TYPE & PARTICIPATION ATTESTATION Check all that apply: CME Certificate Request (MDs and DOs only) SVU-CME Certificate Request Nursing Certificate Request Certificate of Attendance Request Note that AMA PRA Category 1 Credit TM should be claimed in increments of 0.25 hours commensurate with the extent of the learners participation in the activity. For Nursing, learners must participate in an entire session in order to claim credit; credit for partial participation cannot be issued. I certify that I am claiming only the credit commensurate with the extent of my participation in this activity. Signature: Date:
2 THURSDAY, NOVEMBER 6, :00 AM 5:00 PM Track A Basic Phlebology :00 AM 5:00 PM Track B Basic Ultrasound 8:00 AM 5:00 PM Track C Practice Management 8:00 AM 5:00 PM Track D Advanced Phlebology FRIDAY, NOVEMBER 7, :00 AM 8:00 AM Complications in Sclerotherapy 7:00 AM 8:00 AM The Swollen Limb 7:00 AM 8:00 AM Thrombophilia 7:00 AM 8:00 AM Venous Stents 7:00 AM 8:00 AM Treatment Options for Prominent Veins 7:00 AM 8:00 AM Sclerotherapy Workshop 7:00 AM 8:00 AM Compression Workshop 0 0 8:05 AM 9:05 AM Phlebology Year In Review 10:30 AM 12:00 PM Abstract Session 10:30 AM 12:00 PM Ultrasound Session 10:30 AM 12:00 PM Multidisciplinary/Nursing Session :00 PM 3:00 PM Foam and Liquid Sclerotherapy 1:00 PM 3:00 PM The Orphans of Phlebology 1:00 PM 3:00 PM Multidisciplinary/Nursing Session 1:00 PM 3:00 PM What You Need to Know About the Coming ERRA: EHR/Registry/Research/Accreditation
3 FRIDAY, NOVEMBER 7, 2014 (Continued) 1:00 PM 3:00 PM When Skin Talks: Nonvenous Origins Every Vein Doctor Should Recognize 1:00 PM 3:00 PM Ultrasound Session :30 PM 5:00 PM Abstract Session 3:30 PM 5:00 PM Multidisciplinary/Nursing Session 3:30 PM 5:00 PM What s New in Endovenous Ablation 2014? 3:30 PM 5:00 PM World of Phlebology 3:30 PM 5:00 PM Complications of Saphenous Surgical Intervention and How to Avoid Them SATURDAY, NOVEMBER 8, :00 AM 8:00 AM Complications in Sclerotherapy 7:00 AM 8:00 AM Preparing for Vein Center Accreditation 7:00 AM 8:00 AM Novel Anticoagulants 7:00 AM 8:00 AM Microphlebectomy 7:00 AM 8:00 AM Sclerotherapy Workshop 7:00 AM 8:00 AM Duplex Imaging Workshop :10 AM 9:00 AM Keynote Presentation :15 AM 9:45 AM AVF, RSMVF, EVF Abstract Award Presentations 10:30 AM 12:00 PM Abstract Session 10:30 AM 12:00 PM Post-Thrombotic Syndrome 10:30 AM 12:00 PM Outside the Box: What is the Future of Regenerative Therapy
4 SATURDAY, NOVEMBER 8, 2014 (Continued) 10:30 AM 12:00 PM Controversies in Venous and Lymphatic Compression Therapy :30 AM 12:00 PM Ultrasound Session 10:30 AM 12:00 PM Multidisciplinary/Nursing Session 1:00 PM 3:00 PM Endovenous Thermal Ablation 1:00 PM 3:00 PM Natural History of Venous Disease 1:00 PM 3:00 PM Recurrent Varicose Veins 1:00 PM 3:00 PM American Venous Forum (AVF) Session 1:00 PM 3:00 PM Multidisciplinary/Nursing Session 1:00 PM 3:00 PM Society for Vascular Ultrasound (SVU) Session 3:30 PM 5:30 PM From Superficial to Deep Veins 3:30 PM 5:30 PM Venous Imaging 3:30 PM 5:30 PM Veins and Women 3:30 PM 5:30 PM Modern Management of VTE 3:30 PM 5:30 PM Lymphedema and Lipedema 3:30 PM 5:30 PM VCSS and PRO for Beginners 3:30 PM 5:30 PM Multidisciplinary/Nursing Session SUNDAY, NOVEMBER 9, :00 AM 9:00 AM The Role of Venoactive Drugs 8:00 AM 9:00 AM Obesity and Venous Disease 8:00 AM 9:00 AM To Cochrane or Not to Cochrane: How to Influence Insurance CVI Treatment Policies
5 SUNDAY, NOVEMBER 9, 2014 (Continued) 8:00 AM 9:00 AM Politics and Your Medical Practice: How to Transform from an Ostrich to a Golden Goose 9:10 AM 10:30 AM Challenging Cases: Post Mortem Discussion 9:00 AM 3:00 PM Adding Aesthetic Procedures to Your Vein Practice For Office Use Only: TOTALS Date Maximum AMA/SVU Earned Nursing Earned Thursday, November AMA/SVU 4.75 Nursing Friday, November AMA/SVU 7.5 Nursing Saturday, November 8 8 AMA/SVU 7.25 Nursing Sunday, November AMA/SVU 6.75 Nursing Total 29 AMA/SVU Nursing
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