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, as defined in your project.

After you complete this attestation form, it will be submitted to the Ohio AAP program manager for your project, who will ensure the signature of your project’s Local Leader or the QI Project Leader (depending on how your project is organized) is received. The Ohio AAP will then forward completion documentation to the correct board so that you can receive credit for MOC. Credit is submitted approximately once per month, unless a physician indicates the need for expedited processing. 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

First Name
Middle Initial
Last Name and Credentials
If you are not aware of your NPI Number, please use this tool to locate your number: https://npiregistry.cms.hhs.gov/
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.

Signatures

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.
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.
Sending