REQUEST FOR JOINT PROVIDERSHIP
The Perinatal Advisory Council (PAC/LAC) is an accredited provider of continuing education by the Institute for
Medical Quality/California Medical Association (IMQ/CMA) and the Board of Registered Nursing. Agencies who
wish to provide continuing education credits through PAC/LAC must complete and submit the Request for Joint
Providership at least two months prior to the scheduled educational activity. The request for joint Providership,
along with all flyers, brochures, or marketing materials must be approved prior to the continuing education
event. All required materials must be submitted to PAC/LAC at least one month prior to scheduled activity.
Continuing education credits are only valid upon PAC/LAC’s receipt of all required documentation.
SECTION A: JOINT PROVIDER INFORMATION
Date:
Requesting Agency:
Educational Partner:
Contact Person:
Address:
City, State, ZIP:
Tel. No.:
E-mail:
Rev. 9/2014
SECTION B: JOINT PROVIDERSHIP AGREEMENT
The following agreement is set forth between PAC/LAC (Provider) and
(Joint Provider)
the joint providership of the CME Activity entitled
on
(Name of CME Activity)
(Date)
Final Responsibility and Authority
As the accredited provider, PAC/LAC is the final arbitrator on all matters regarding this CME activity and it is responsible for
the management and operation of this activity in accordance with all rules and regulations of the Institute for Medical
Quality/California Medical Association (IMQ/CMA).
Role and Responsibility of the Joint Provider
The following functions will be the responsibility of the Joint Provider with the approval and direction of the accredited
provider:

Completion of PAC/LAC’s Request for Joint Providership and maintenance of required documentation regarding
this activity in accordance with PAC/LAC’s procedural formats

Design and production of promotional brochures that will be mailed to the target audience and obtaining of
required approvals from PAC/LAC prior to printing and distribution

Design and production of syllabus or hand-out materials, working in conjunction with the faculty

Management of and adherence to the approved budget for this activity. Submission of all financial agreements,
budget and detailed receipt and expenditure to PAC/LAC

Design and production of the evaluation instrument for this activity in accordance with the example provided
by PAC/LAC

Management and staffing of the activity, ensuring that attendees sign-in appropriately, complete evaluation
and receive credit

Provide the activity’s moderator with written notes regarding introductory remarks concerning communication
of faculty disclosures, and acknowledgement of commercial supporters.

Assurance that no funds or other in-kind resources from the commercial supporter(s) are paid or provided
directly to any faculty member

Submission of all required documentation within 30 days after the scheduled activity
Responsibilities of PAC/LAC (as the accredited provider)
PAC/LAC’s duties and responsibilities include but are not limited to the following:

Assure compliance with all applicable ACCME Essential Areas and policies and other policies and regulations of
the AMA with regard to accredited continuing medical education activities.

Participation in and approval of activity’s planning process and needs assessment.

Review of clinical content for syllabus.

Oversee and manage the joint provider for compliance with the above.

Production of sample Certificate of Credit for physicians and Certificate of Attendance for non-physicians.

Receipt of grant from commercial supporter(s), unless agreed to in writing that the grant shall go to the Joint
Provider.

Issuance of faculty honoraria, unless otherwise agreed to in writing with the Joint Provider
_________________________________
Joint Provider Signature
Date
________________________________
PAC/LAC CME Coordinator
Date
Rev. 9/2014
SECTION C: ACTIVITY INFORMATION
Date of CME Activity:
Name of CME Activity:
Time & Location:
Course Director/Chair:
Units
Requested:
CME (Physicians)
Continuing Education Contact Hours (Nurses)
Continuing Education Contact Hours (Licensed
Clinical Social Workers/Marriage Family Therapists)
(Each unit corresponds to each lecture’s length of time. The Board of Registered Nursing recognizes a 50-minute hour; the
IMQ/CMA abides by a 60-minute hour; the Board of Behavioral Sciences recognizes a 60-minute hour. Breaks, lunch,
welcome and introductions do not count as educational time.)
Educational Needs Assessment
What physician professional practice gap(s) does this activity address? (Choose at least one)
Knowledge (e.g. learner’s understanding, information or beliefs)
Competence (e.g. learner’s skills, abilities, or strategies)
Performance (e.g. learner’s practice, process, or behavior)
Describe the physician professional practice gap(s) indicated above (i.e. what the gap is) and include a
description how this need was identified (i.e. how do we know this is a gap). Take into consideration the
learner’s scope of practice or potential scope of practice and barriers to change.
Course Learning Objectives
CME activities must be designed to change physician competence, performance, or patient outcomes.
This activity is designed to change:
Competence (e.g. intent or readiness to change, change in skills, ability to apply learning to
practice)
Performance (e.g. change in physician behavior or practice)
Patient outcomes (e.g. patient health status, health measure or quality of care)
List below the overall desired outcomes (i.e. objectives) of this educational activity.
NOTE: Desired outcomes must be in terms of physician competence, performance or patient outcomes. An
increase in physician knowledge is NOT sufficient.
Rev. 9/2014
SECTION C: ACTIVITY INFORMATION (cont’d)
Desirable Physician Attributes
Activities/educational interventions must be developed in the context of desirable physician attributes. What
are the desirable physical attributes related to this topic/outcome? Check all that apply
IOM Competencies
Provide patient-centered care
Work in interdisciplinary teams
Employ evidence-based practice
Apply quality improvement
Utilize informatics
ACGME Competencies
Patient Care
Medical Knowledge
Practice-based learning & improvement
Interpersonal and communication skills
Professionalism
Evaluation
How will you measure changes in learner’s competence, performance or changes in patient outcomes?
 Attach a copy of the evaluation tool or form for this activity
Target Audience
The content of this educational activity is designed to meet the needs of the following target groups: (List
physician specialists)
Event Format
State the educational format (e.g. didactic lecture, case presentations, panel discussion, interactive workshop,
etc.) and WHY this format was chosen. Educational formats must be appropriate and support the setting,
objectives, and desired results of this activity.
Cultural and Linguistic Competency Assessment (AB 1195)
Discuss evidence of health disparities that have been linked to cultural or linguistically related practice gaps (i.e.
physician knowledge, competence or performance) found within the relevant physician learners/patient
community. If no cultural or linguistic health or health care disparities or practice gaps are identified, provide a
list of the types and places searched.
Rev. 9/2014
SECTION C: ACTIVITY INFORMATION (cont’d)
Brochure/Flyer/Marketing Materials:
 Attach a draft of the agenda, brochure, flyers, and/or marketing materials.
All brochures, flyers, and/or marketing materials must be submitted to PAC/LAC for review and approval at least
two months prior to the activity and prior to distribution. They must contain:
-
PAC/LAC listed as the joint provider of the event
Intended audience including physician specialists
Learning Objectives
Agenda (list time, topic, faculty for each time slot)
Name and credentials of program faculty
Cost (if event is free, it must state so)
Cancellation or refund policy
Materials supplied (e.g. course syllabus, continental breakfast, lunch, etc.)
Acknowledgement of commercial support (i.e. Commercial support provided by…)
Appropriate CME and/or CEU language:
o For Physicians: This activity has been planned and implemented in accordance with the Institute
for Medical Quality and the California Medical Association’s CME Accreditation Standards
(IMQ/CMA) through the Joint Providership of the Perinatal Advisory Council: Leadership,
Advocacy and Consultation (PAC/LAC) and [name of non-accredited provider]. PAC/LAC is
accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to
provide continuing education for physicians. PAC/LAC takes responsibility for the content,
quality and scientific integrity of this CME activity. PAC/LAC designates this live activity for a
maximum of [XX] AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit
commensurate with the extent of their participation in the activity. This credit may also be
applied to the CMA Certification in Continuing Medical Education.
o For Nurses: The Perinatal Advisory Council – Leadership, Advocacy and Consultation (PAC/LAC)
is an approved provider by the California Board of Registered Nursing Provider CEP 5862. This
course is approved for XX contact hours of continuing education credit.
o For LCSW or MFT: PAC/LAC is an approved provider by the California Board of Behavioral
Sciences. The course meets the qualifications for XX hours of continuing education credit for
LCSWs and MFTs as required by the California Board of Behavioral Sciences. PAC/LAC’s provider
number is PCE5563.
Rev. 9/2014
SECTION D: PLANNING COMMITTEE
All members of the planning committee must make a disclosure of any financial relationship(s) with any
commercial interest. Each Planning Committee Member must complete and sign a Faculty and Planning
Committee Disclosure Form.
 Submit a completed and signed Faculty and Planning Committee Disclosure Form for each member. This is
required at least two months prior to the educational activity. See “Additional Forms”
 Completed and signed disclosure forms from all members of the Planning Committee members must be
submitted to PAC/LAC by the Joint Provider.
 Submit this page with all of the completed and signed disclosure forms.
List all members of the Planning Committee for this activity: (attach additional sheets if necessary)
Planning Committee Member
Any Financial Relationship?
Disclosure Form Attached
(Yes/No)
Rev. 9/2014
SECTION E: FACULTY MEMBERS
 All faculty members must submit the following at least one month prior to the activity:
o CV/Resume
o Completed and signed Content Validation Form, AND
o Completed and signed Faculty and Planning Committee Disclosure Form.
 See “Additional Forms” for required forms
 All required faculty forms above must be submitted to PAC/LAC by the Joint Provider.
 Submit this page with all of the required forms listed above.
List all faculty members (e.g. speakers, panelists, moderators, course director, etc.) for this activity.
Check off all materials attached to this form (attach additional sheets if necessary).
FACULTY
CV/RESUME
CONTENT
VALIDATION
Any Financial
Relationship?
DISCLOSURE
(Yes/No)
Rev. 9/2014
SECTION F: FINANCIAL & COMMERCIAL SUPPORT
This section must be completed by the Joint Provider and submitted to PAC/LAC.
FINANCIAL SUPPORT
Income and expense statements of CME activities must be available for review. All organizations requesting
joint providership must submit a detailed budget for the CME activity, regardless of the source (i.e. whether it is
from a commercial interest or non-commercial interest). Organizations must also submit documentation
regarding educational grants from both commercial and non-commercial interest.
 Attach a copy of the proposed budget for this CME activity. The budget must list all sources of funding
and detail all line item expenses expected for this CME activity. Please see budget template for an
example.
 Submit a copy of the financial agreement or Letter of Agreement for Financial Support from each source of
funding or educational grant (commercial and non-commercial). It must state the amount and purpose of
the grant.
Please provide a list of any and all organizations providing financial support (commercial or non-commercial) to
this CME activity. Please complete the table below with as much information as possible (Attach additional
sheets if necessary)
ORGANIZATION
REPRESENTATIVE
NAME
E-MAIL ADDRESS
&TEL. NO.
AMOUNT
WRITTEN
AGREEMENT
Rev. 9/2014
SECTION F: FINANCIAL & COMMERCIAL SUPPORT (cont’d)
COMMERCIAL SUPPORT
Commercial Support is any financial or in-kind contributions given by a commercial interest, which is used to pay
all or part of the costs of a CME activity. Commercial interest is defined as any entity producing, marketing, reselling or distributing healthcare goods or services consumed by, or used on patients. Providers of clinical
service directly to patients are not considered to be commercial interests.
Will you have Commercial Support for your CME activity?
Yes
No
If yes, read the following information carefully and respond to all questions thoroughly.
If no, leave the rest of this section blank.
In cases of Joint Providership, written agreements for commercial support between the accredited provider
(PAC/LAC) and the commercial interest are required and need to be signed prior to the activity taking place.
MODE OF PAYMENT
For joint-providership CME activities, PAC/LAC may delegate authority to manage the funds to the non-accredited
provider (joint provider) with the condition that they will abide by the terms and conditions of the ACCME
Standards for Commercial Support for Continuing Medical Education (available upon request).
Receipt of grant from commercial support will go to:
Joint-Provider
PAC/LAC
Educational grants made payable to PAC/LAC
5530 Corbin Ave., Suite 323
Tarzana, CA 91356
TERMS & CONDITIONS REGARDING COMMERCIAL SUPPORT
PAC/LAC is committed to presenting CME activities that promote improvements or quality in healthcare in
compliance with ACCME Standards for Commercial Support for Continuing Medical Education. As the joint
Provider representative, I agree to abide by the ACCME Standards for Commercial Support for Continuing
Medical Education; acknowledge commercial support in activity brochures, syllabi, and other materials; and
upon completion of the CME Activity, furnish PAC/LAC a report concerning the expenditure of funds provided.
Signature
Date
Joint Provider Representative Name (Print Name)
Rev. 9/2014