Office of Continuing Medical Education
Joint Provider and CME Fee Agreement
1. Activity Title:
2. Activity Date:
3. Name and title of person completing form:
4. Address:
5. Telephone: (
)
6. Email Address:
7. Name of Organization(s) Requesting Joint Provider (List all)
8. Has this organization been a joint provider with the UAMS COM in the past?
9. Name of Course Director or Program Chair, if different from #3 above:
10. Is a UAMS College of Medicine faculty member involved in the planning?
If yes, Name of faculty member:
Name of UAMS COM Department:
If no, proceed to signature.
11. In what capacity is the faculty member involved?
Course Director
Planning Committee
12. Will the faculty member’s assistant be involved?
If yes, assistant’s name and title:
Yes
Yes
No
Unsure
No
, and proceed to question 11.
Other, please explain.
Yes
No
The non-accredited provider will pay a standard fee for CME accreditation and will be a joint provider for the activity
listed in this document. This includes the responsibilities listed above. Fees for additional services not covered on the
list will be invoiced separately as agreed upon by both parties.
CME Accreditation and Joint Provider Fee
Per Participant Fee (invoiced post-activity)
$
$
By signing this form, the accredited provider and non-accredited provider(s) have agreed to enter into a joint
provider relationship and carry out the respective responsibilities as outlined below. The UAMS College of Medicine
Office of Continuing Medical Education reserves the right to withdraw joint providership and CME credit if any the
above requirements are not fulfilled.
ACCREDITED PROVIDER
NON-ACCREDITED PROVIDER
Signature
Signature
Print Name
Print Name
Date
Date
Return this page, signed, to the OCME
By email: flemingkarend@uams.edu
By fax: 501-661-7968
Mail: UAMS COM OCME, 4301 W. Markham St. Slot 525, Little Rock, AR 72205
RESPONSIBILITIES OF THE JOINT PROVIDERS (keep this page for your file)
The following agreement outlines the responsibilities between the University of Arkansas for Medical Sciences (UAMS) College
of Medicine Office of Continuing Medical Education (henceforth referred to as the Accredited Provider) and organization(s)
listed above (henceforth referred to as the Non-accredited Provider) as joint providers of the above listed educational activity. A
timeline, to be agreed upon in the initial consultation meeting, MUST be adhered to or the CME credit approval could be delayed
or not awarded at all.
Accredited Provider Responsibilities
Non-accredited Provider(s) Responsibilities Prior to Approval
(UAMS COM) Prior to Approval

Participate in initial consultation meeting
 Hold an initial consultation meeting
o Discuss application process
o
Discuss the CME application process
o Determine if additional services are desired
o Determine services needed
o Agree upon the CME fee
o Agree upon CME fee and determine if additional

Submit a pre-application proposal form to the OCME
services will be needed
 Adhere to the OCME timeline for application and document
 Review the activity proposal form
submissions
 Have a role in the planning process
 After approval of pre-application, complete and submit the
o Involvement as course director (faculty member) OR;
entire planning document and attachments to OCME –
o Involvement as a planning committee member
including (list may vary for enduring materials)
(Identify a faculty member, CME Associate, or CME
o Joint Provider Agreement
Staff member); OR
o List of planners
o Recommend methods for outcomes data
o Needs assessment data
collection/measurements
o Educational objectives
o Agenda (with time, speakers, and topics)
 Review the application and documentation
o Needs assessment
o Faculty invitation letter
o Objectives
o CVs or Bio forms for all speakers
o Design
o Disclosure forms completed and signed by ALL planners,
o Faculty Selection
moderators, and speakers
o Evaluation/Outcomes
o Commercial Support agreements, if applicable
o Disclosure forms (from planners/speakers
o Preliminary Budget
o Commercial Support
 Submit initial application fee
 Provide feedback to non-accredited provider about
After approval
application, if necessary
 Submit promotional materials (flyer, brochure, etc.) to
 Provide non-accredited provider with documentation
OCME for approval prior to printing
when final approval is awarded
 Send additional documentation to complete the file, if
necessary
 Review promotional materials and provide feedback
During the activity
 Invoice applicant for fees, if necessary
 Follow the OCME guidelines
 Provide consultation and feedback to non-accredited
provider in soliciting commercial support, if needed
 Provide disclosure information to the audience prior to the
After approval
beginning of the activity. This must be done even if there is
nothing to disclose.
 Follow-up, as needed to collect additional
documentation, if necessary
 Acknowledge commercial support to the audience prior to
the beginning of the activity, if applicable.
 Provide templates, as needed (sign-in sheets, evaluation
forms, CME certificates)
 Collect event attendance information (credit claim forms)
After the activity
 Collect evaluation data from attendees
 Provide post-activity follow-up notices
After the activity
 Review final documentation for compliance issues
 Submit closing report and documentation within 30 days
o Attendance records (credit claim forms)
 Issue certificates, if not provided for the activity
o Evaluation data summary
 Enter credits for physicians requesting CME credit
o Verification of disclosure
 Maintain CME credit information for 6 years
o Verification of acknowledgement of commercial
 Maintain CME application and documentation for 4 years
support, if applicable
o Final detailed budget report
o Handout materials
o Per Participant fee (when applicable)
2
June 2015