Organizational Intent to Apply -- Joint Accreditation Process
Our organization meets the eligibility criteria set for providers wishing to engage in the Joint Accreditation
process. Therefore, we are providing ACCME, ACPE, and ANCC with written confirmation of our intent to
apply for joint accreditation.
An organization is eligible to seek accreditation as a joint provider of continuing education for the healthcare
team if…
 The organization’s structure and processes to plan and present education designed by and for the
healthcare team have been in place and fully functional for at least the past 18 months;
 At least 25% of the educational activities delivered by the organization during the past 18 months are
comprised of education designed by and for the healthcare team;
 The organization engages in the Joint Accreditation process and demonstrates compliance with the
criteria and, if currently accredited, any associated accreditation policies required by ACCME, ACPE or
ANCC.
Prior to submitting the Intent to Apply form, all organizations must contact Joint Accreditation Staff
(info@jointaccreditation.org) to discuss the eligibility requirements and the timeline to pursue Joint Accreditation.
Please provide the following information and submit this form with the Eligibility Review Fee (see current fee schedule).
Organizational Information
Name of Organization:
Date :
Provider ID:
Accreditation (check all that apply)
Most recent
accreditation cycle
dates:
From
To
Accreditation Council for Continuing Medical Education (ACCME)
ACCME Recognized Accreditor:
Accreditation Council for Continuing Pharmacy Education (ACPE)
American Nurses Credentialing Center (ANCC)
ANCC Accredited Approver:
Our organization is not currently accredited by ACCME, ACPE, or
ANCC
Number of CE activities offered by your organization in the last 18 months:
Total number of CE activities designed by and for the health care team in the last 18 months:
Primary Contact for Organization:
Note: The name and information provided for the organization’s primary contact will be used as the contact information
for communicating with the organization. Postal deliveries, shipments, telephone calls, email and fax transmissions will
be directed to the individual identified as the Primary Contact using the contact information provided below.
Name
Title
Address
Telephone number
Fax number
e-mail address
JOINT ACCREDITATION INTENT TO APPLY – December 2014
ACCME, ACPE & ANCC®
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Chief Executive Officer of Organization:
Name
Title
Address
Telephone number
Fax number
E-mail address
Narrative Response:
Please provide a narrative response for each of the following questions:
Organizations
interested in
becoming jointly
accredited must
define the
components of the
continuing education
program both
structurally and
operationally. Please
describe your
organization (500
words or less)
Describe the general
process for planning
interprofessional
activities (500 words
or less)
Generally, who is
your target audience
for continuing
education activities?
Nurses
Pharmacists
Physicians
Other (please list other professions):
Did you use an
outside consultant to
assist in the
preparation of these
materials?
Yes
No
If yes, please provide the following information:
Consultant Name
Organization
Telephone number
E-mail address
Website
JOINT ACCREDITATION INTENT TO APPLY – December 2014
ACCME, ACPE & ANCC®
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Date Self Study Report and Activity Files will be submitted:
For November decision,
July 1
For July decision,
I attest, by my signature below, that I am duly authorized by
Accreditation and to make the statements herein.
March 1
to submit this application for Joint
On behalf of the organization, I:
 have read the Joint Accreditation eligibility requirements and criteria.
 understand that the organization is subject to all eligibility requirements and criteria for
accreditation as described in the current Joint Accreditation framework and any updates
thereto.
 understand that accreditation depends on successfully meeting eligibility requirements and
accreditation criteria and that continued accreditation is dependent upon continued
compliance
 attest that our organization is not a commercial interest and is not owned by a commercial
interest (as defined by the ACCME Standards for Commercial Support: Standards to
Ensure Independence)
 hereby certify that the information provided on and with this application is true, complete,
and correct.
 understand that the information that is considered ‘public information’ by the Accreditors,
including certain information about accredited providers, may be published and released by
the Accreditors, including on the Joint Accreditation, ACCME, ACPE, and ANCC websites
 attest that the materials submitted for Joint Accreditation (self study report, activity files,
other materials) will not include individually identifiable health information, in accordance
with the Health Insurance Portability and Accountability Act (HIPAA), as amended.
 understand that if the organization does not receive Joint Accreditation, the organization
may request to apply for accreditation individually through ACCME, ACPE and/or ANCC
provided that the organization submits an application and the required fee understand that if
the organization does not receive Joint Accreditation, and the organization chooses not to
apply for accreditation individually through ACCME, ACPE and/or ANCC, then the current
accreditations, if accredited, will expire at the currently scheduled expiration date.

The following statements are the responsibilities of providers related to the American
Medical Association’s Physician Recognition Award Credit System: The AMA has set forth
expectations of providers that designated CME activities for AMA PRA Category 1 Credit TM.
The ACCME helps to facilitate the process by which accredited providers supply the AMA
with evidence of their performance-in-practice related to AMA expectations. We
acknowledge that, pursuant to standards established by the AMA, an organization
accredited by the ACCME may designate educational activities for AMA PRA Category 1
CreditTM. We also acknowledge that, pursuant to standards established by the AMA, in
order for an educational activity to qualify for AMA PRA Category 1 Credit TM, the activity
must meet additional requirements beyond its delivery by an ACCME accredited provider.
These requirements are described on the AMA website (www.ama-assn.org).
 We understand and consent to the collection and sharing of information with the AMA about
JOINT ACCREDITATION INTENT TO APPLY – December 2014
ACCME, ACPE & ANCC®
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the organization’s performance-in-practice with certain AMA PRA Standards as a service
both to the organization and the AMA PRA. This information will be limited to 1) evidence
of the use of the credit designation statement and 2) indication of the appropriate level
within new skills and procedures training (if applicable).
Signature
Submit Form and Fee to:
Dimitra Travlos, PharmD, BCPS
Continuing Education Provider Accreditation
Accreditation Council for Pharmacy Education
135 South LaSalle Street, Suite 4100
Chicago, Illinois 60603
JOINT ACCREDITATION INTENT TO APPLY – December 2014
ACCME, ACPE & ANCC®
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