2021 ACPC Quality Network - Attestation Form

ACPC Quality Network - Physician Attestation Quality Improvement Activities

This attestation must be completed by an individual physician that has participated in an approved ACPC Quality Network QI activity and has satisfied all of the participation requirements for MOC Part IV credit to be awarded.

Section 1: Participant Information

Provide the following details:

Unique Board identification number:

Last Name:

First Name:

Middle Initial:

Individual National Provider Identifier (NPI):

Email Address:

Title of quality improvement effort: (Please select only one response.)

ACPC Quality Network - Appropriate Measurement and Counseling for Pediatric Cardiac Patients with BMI > 85%
ACPC Quality Network - Genetic Testing in Patients with Tetralogy of Fallot
ACPC Quality Network - Noninvasive Imaging
COVID-19
Non-Invasive Imaging Part 2
Outpatient Evaluation of Chest Pain

Participation: Indicate the timeframe for the three quarters of data submission that you participated in the QI effort:

Start Date for Baseline of Data:

Format: mm/dd/yyyy

End Date of Second PDSA Cycle:

Format: mm/dd/yyyy

What is your date of birth?

Date of Birth (MM/DD/YYYY):

Format: mm/dd/yyyy