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

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.

Project Feedback

Please answer the below questions on the impact of the project.
  Yes No
Did you review and agree with the project aim?
Did you improve care for your patients through this project?
Did the interventions address important issues for your patients?
Did you change your practice as a result of this project?

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