"Live at the Forum: Medical Dental Integration at the Community Level" Credit Documentation

100% of survey complete.

Please complete the following credit documentation form. Please enter your name and credentials exactly as you would like them to appear on your certificate of completion and provide your contact information to be kept on file and for sending your certificate. Please note that this information is kept separate from your answers to the evaluation.

Once this credit documentation is received, a certificate of completion will be generated and sent to you.

Thank you!

Continuing Education Information:
North Country Health Consortium/NNH AHEC is an approved provider of continuing nursing education by the Northeast Multistate Division, an accredited Approver by the American Nurses Credentialing Center’s Commission on Accreditation.
This activity was approved for 5.5 Nursing Contact Hours. Activity # 335

The North Country Health Consortium/NNH AHEC, accredited by the NH Medical Society, designates this live activity for a maximum of 5.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

For Other Professionals: 5.5 Professional Hours of Continuing Education.

Credit Documentation Information:

Question Title

* Please identify the sessions that you attended at the forum (check all that apply):

8:40-11:45am: Morning Panel

1:00-4:00pm: Afternoon Panel

Question Title

* The following information WILL NOT be linked to the evaluation previously completed.

Name

Credentials

Email Address

Company

Home or Business Address

Home or Business Address 2

City/Town

State

Zip

Phone Number

Question Title

* Preference for Receiving Certificate:

Mailed to Address Provided Above

Thank you! Once this credit documentation is received, a certificate of completion will be generated and sent to you within one month.