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.
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.