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

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/

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 *

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 *

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.