MOC Part IV Attestation Form MOC Part IV Attestation Form MOC Part IV Attestation Form Complete this Attestation Form if you are a Certified physician seeking credit under Maintenance of Certification for Performance in Practice. To be eligible for credit, you must have satisfied all requirements for meaningful participation. After you complete this attestation form, submit it to your project’s Local Leader or the QI Project Leader (depending on how your project is organized) for signature. The Leader will forward completion documentation to the correct board so that you can receive credit for MOC. The proper board will only receive documentation of your successful completion of the project and identifying information to ensure your record is accurately updated. Attestation of Meaningful Participation Participating Physician Name * First Name Middle Initial * Middle Initial Last Name * Last Name and Credentials Participating Physician Email Address * Participating Physician Date of Birth * Participating Physician NPI Number * If you are not aware of your NPI Number, please use this tool to locate your number: https://npiregistry.cms.hhs.gov/ Please select your ABMS Certifying Board: ------ American Board of Allergy & Immunology American Board of Anesthesiology American Board of Dermatology American Board of Emergency Medicine American Board of Family Medicine American Board of Internal Medicine American Board of Medical Genetics and Genomics American Board of Obstetrics & Gynecology American Board of Ophthalmology American Board of Orthopaedic Surgery American Board of Otolaryngology American Board of Pathology American Board of Pediatrics American Board of Physical Medicine & Rehabilitation American Board of Plastic Surgery American Board of Preventive Medicine American Board of Psychiatry & Neurology American Board of Radiology American Board of Surgery American Board of Thoracic Surgery Your Board ID Number * Sponsor Organization I satisfied the below Meaningful Participation requirements during my MOC Cycle (Not Project Dates) * Identify the date range for the MOC Cycle that this project will satisfy the requirements of; e.g. December 2011-December 2016 - This is NOT the dates that you participated in the project, it is the specific dates for your MOC Cycle. Quality Improvement Project Title * --------- Adolescent Health QI2U (End Date: July 2018) Building Mental Wellness (BMW) Self-Directed Activity (End Date: Ongoing) Education and Sleep Environment LC – Wave 2 (End Date: Spring 2016) Education and Sleep Environment (EASE) Self-Directed Activity (End Date: Ongoing) Good4Growth Primary Care LC – Wave 1 (End Date: Spring 2016) HPV QI Program - Wave 1 (End Date: June 2017) Injury Prevention/Safe Sleep LC – Wave 3 (March 2015 - November 2015) Injury Prevention Safe Sleep Self Directed Activity (End Date: Ongoing) Parenting at Mealtime and Playtime LC – Wave 3 (Dec. 2015 - June 2016) Parenting at Mealtime and Playtime – Wave 4 (End Date: Ongoing) Preschool Vision Screen LC - Wave 3 (End Date: Summer 2016) Preschool Vision Screening – Wave 4 (End Date: Ongoing) Transforming Adolescent Care LC – Wave 2 (End Date: May 2017) Ohio QI2U-MenB Program - Wave 1 (End Date: July 2018) Meaningful Participation Requirements I provided direct or consultative patient care in this improvement project. I completed one or more tests of change to improve care. My data and/or my team’s data were collected and submitted in keeping with the project measurement plan, and I reviewed my own data during the project. I attended four or more project meetings /calls. I was active in the project for the minimum duration required by the project. I met these requirements by the end date of the selected project. Signatures Participating Physician * Draw It Type It Clear By signing in the box above (either by using your mouse or by typing your name), you are attesting that you participated in the project as described in the sections above. Practice Project Leader * By typing the name of the Practice Project Leader in the box above, you are indicating that this person agrees that the individual listed above was indeed an active participant in this project and met all requirements. The individual whose name is listed above has been designated by this QI project to review and approve attestations of participation for this physician. In some cases the Practice Project Leader will be the same as the Participating Physician; in these cases, we still ask you to type your name as a commitment that you were indeed an active participant in the project and met all requirements.
