Provider Submissions

CME Application Form

Application for CME Accreditation for Educational Courses

United for Healthcare Workers, LLC is a service that helps consolidate materials for instructors, educational institutions, and platforms to apply for AMA PRA CreditTM & ACCME Credit Accreditation through MNI Great Lakes ECHO, which is accredited by the Michigan State Medical Society to provide medical continuing education for clinicians. The following information is required to get a course approved for CME/CEU accreditation. Please fill out this form in its entirety for MNI Great Lakes ECHO to successfully process and approve your course and to help the educational entity host your course. By filing out this application, you acknowledge that United For Healthcare Workers, LLC is not responsible for any content provided by applicants, nor any contract disputes between applicants and MNI Great Lakes ECHO and/or educational institutions/platforms, nor any and all potential conflicts or disputes that might arise through the public or other sources.

Instructor's Name(Required)

Prefix First Last Suffix/Credientials (NA if none)

Email(Required)

Phone(Required)

Course Title + Instructor + Professional Title/Credentials(Required)

i.e. Apraxia of Speech Assessment and Treatments By: Jane Doe, MS, CCC-SLP, Speech Language Pathologist

Course Learning Objectives (4 required)(Required)

Column 1

Column 2

Column 3

Column 4

Short Summary of Course(Required)

Total CME/CEU Hours(Required)

Upload Lecture Slides

Drop files here or

Max. file size: 32 MB, Max. files: 100.

If slide deck file is too large, please provide a weblink (i.e. Dropbox) below where we may view and download your slide deck.

Weblink to downloadable slide deck

Upload Course Cover Photo Cover

Max. file size: 32 MB.

Course Cover Photo

Upload Photo of Instructor

Max. file size: 32 MB.

Instructor’s Photo that may be used in marketing and promotional materials for Course and course affiliations (i.e. Educational Institution/Event(s).)

United for Healthcare Workers, LLC will share this content with MNI Great Lakes ECHO CME Program along with the following course affiliation entities:

List educational institutions and organizations whom you plan to host your course through

Disclose All Commercial Interest and Relevant Financial Relationships

The MNI Great Lakes ECHO CME Program must ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. Therefore, all participating activity organizers, program directors, committee members, and lecturers in a sponsored event are expected to disclose any relevant financial relationships or other relationship 1.) with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in an educational presentation and 2.) with any commercial supporters of the CME activity. The intent of this disclosure is not to prevent a speaker, presenter, event organizer or committee member who may have influence over material from contributing, but rather to provide activity organizers and listeners with information on which they can make their own judgments. It remains for the audience to determine whether the speaker’s interests or relationships may influence the presentation with regard to exposition or conclusion. Although organizers and committee members may not actually present at a planned event, their responsibility of program planning, oversight and credit approval places them in positions to potentially influence educational events. The significance to influence, therefore requires full disclosure of potential conflicts of interests in the fulfillment of their responsibilities. The Accreditation Council for Continuing Medical Education (ACCME) defines a commercial interest as any entity producing, marketing, re‐selling, or distributing health care goods or services consumed by, or used on, patients. The ACCME defines “‘relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

Have you, or your spouse/partner, had a relevant financial relationship in the last 12 months with an ACCME‐defined commercial interest that will be discussed in the CME activity or in your presentation?(Required)

Yes

It is the speaker's responsibility to disclose any presentation of off‐label uses of a product. Do you anticipate your presentation to include discussion of any off‐label uses of a product?(Required)

Yes

Please explain off-label product discussions

Affirmation(Required)

I attest to the following:

1.) I will prepare fair & balanced presentations that are objective & scientifically rigorous. Content – including therapeutic options, recommendation, or emphasis – will be well‐balanced, evidence based where possible & unbiased. Source and type of evidence will be made clear to the participants and be HIPAA compliant, i.e., I will only use de‐identified patient information. No single product or service will be over represented when other equal but competing products or services are available for inclusion.

2.) I will use generic names to the extent possible when discussing specific health care products or service. If I need to use trade names, I will use trade names from several companies when available, & not just trade names from any single company.

3.) If I have been trained or utilized by a commercial entity or its agent as a speaker for any commercial interest, the promotional aspects of that presentation will not be included in any way with this activity.

4.) If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principles & methods, & will not promote the commercial interest of the funding company.

5.) The handouts and slides will not include my company logo other than on the first slide (the copyright symbol may be included on each of the slides.

6.) I will not include any advertising, trade names or product‐group messages in any of the educational materials for this CE activity (slides, abstracts, handouts, etc.).

7.) I understand that MNI and activity planners need to review my presentation &/or content prior to the activity & I have provided my educational content and resources with this form. If I make changes to my presentation after submitting this form that could affect my compliance with accreditation or the activity planners agreement, I will notify all parties prior to live event and submit a new form.

8.) I have not and will not accept any honoraria, additional payments or reimbursements beyond that which has been agreed upon directly with Sponsor of this activity.

8.) I understand that participants will be asked to evaluate these requirements.

By electronically signing my name, I agree to the terms set forth in this application:(Required)

Full Name