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HOUSE OF D E L E G AT E S A N N U A L S C I E N T I F I C M E E T I N G

PATIENT SAFETY RISK MANAGEMENT: WHAT EVERY PHYSICIAN S H O U L D K N O W

J une 24-28, 2013

CONRAD SAN JUAN CONDADO PLAZA SAN JUAN, PUERTO RICO


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HOUSE OF D E L E G AT E S A N N U A L S C I E N T I F I C M E E T I N G

I nvitation to AAPS D iplomates , M embers , and C olleagues You are cordially invited to join your fellow Diplomates, Members, and Other Health-Care Professionals For discussions and up-to-date information on Patient Safety & Risk Management: What Every Physician Should Know Monday, the Twenty-Fourth of June through Friday, the Twenty-Eighth of June, Two Thousand Thirteen


A dvance Y our C areer ! N etwork ! L earn ! R elax & E njoy ! A ttend the 2013 A nnual M eeting ! G reat H otel in G reat L ocation • Easy access from many US cities • Discover the sophisticated style of Conrad San Juan Condado Plaza where tropical luxury beckons • Close to Old Town San Juan, shopping, dining, the beach, and more

F lexible O ptions • Customize your schedule – choose the sessions that work for you the Business Package or the CME Package.

N ew T his Y ear - B edside U ltrasound W orkshop • Choose from two sessions – Wednesday, June 26, or Friday, June 28

G reat P ricing • Registration packages allow you to pay only for the portion of the meeting you plan to attend. • Welcome Reception included in all packages.

G enerous D eadlines • Take advantage of best prices during Early Registration THIS IS YOUR BEST BUY!!! • Early Registration up to March 22, 2013 • Still-Time-To-Register up to May 31, 2013


O verall M eeting O bjectives • Provide physician specialists with up-to-date information about Patient Safety & Risk Management. • Provide a forum in which to discuss developing and emerging issues in your specialty or sub-specialty. • Plan and conduct business that will further strengthen the mission of the AAPS, its affiliated Academies of Medicine, and its Boards of Certification. • Encourage collegial relations that enable individual members to pursue their professional goals of participation in the Association’s activities.

I ntended A udience ABPS Diplomates and AAPS Members in: Anesthesiology

Internal Medicine

Dermatology

Obstetrics & Gynecology

Diagnostic Radiology

Ophthalmology

Disaster Medicine

Orthopedic Surgery

Emergency Medicine

Plastic & Reconstructive Surgery

Family Medicine Obstetrics

Psychiatry

Family Practice

Radiation Oncology

Geriatric Medicine

Surgery

Hospital Medicine

Urgent Care Medicine


A ccreditation S tatement The American Association of Physician Specialists, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CME C redit S tatement Examination Development Workshop I, June 24 – The AAPS designates this test-item writing activity for a maximum of 7 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Examination Development Workshop II, June 25 – The AAPS designates this test-item writing activity for a maximum of 5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 2013 Annual Scientific Meeting – June 26 and 27: The AAPS designates this live activity for a maximum of 16 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

E arn CME credits by participating in . . . Up to 16.0 CME credits for Scientific Presentation sessions Up to 12.0 CME credits for Examination Development Workshops Up to 7.5 CME credits for Medical Ethics course Up to 7.75 CME credits for Ultrasound Workshop

CME C ommittee Kenneth M. Flowe, M.D., FAAEP, MBA, Co-Chair

Jack V. Greiner, D.O., PhD, FAASS, MA

Stephen A. Montes, D.O., FAASOS, Co-Chair

Jerry R. Majers, D.O., FAAIM, FAAGM

Muhammad A. Ahmed, M.D. Lingappa S. Amernath, M.D.

Surinder K. Kad, M.D., FAAIM, MPH, MBA Herbert Pardell, D.O., FAAIM Luis M. Velasco, M.D.


B edside U ltrasound W orkshop 7.75 CME credits S eparate registration required $799.00 O ne - day course : W ednesday , J une 26 F riday , J une 28

B edside ultrasound has been shown to : • Quicken diagnoses • Enhance patient management • Rule in/out emergent conditions • Decrease procedural complications • Increase patient satisfaction

A ccreditation S tatement The American Association of Physician Specialists, Inc., (AAPS), is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CME C redit S tatement The American Association of Physician Specialists, Inc., designates this live activity for a maximum of 7.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


R egistrants will : • Learn Bedside Ultrasound from the experts • Participate in lectures from top experts in the field • Practice at hands-on stations with maximal benefit – 1 instructor per 5 registrants • Review basic bedside ultrasound applications including: •

Rapid Ultrasound in Shock (RUSH) protocol

Extended FAST scan for trauma and unexplained hypotension

Focused echocardiography for contractility and pericardial effusion assessment

Aorta evaluation for abdominal aneurysm

Renal assessment for hydronephrosis

IVC evaluation for volume status

Gallbladder assessment for gallstones and cholecystitis

Thoracic ultrasound for pneumothorax/pleural effusion/pneumonia assessment

Two-point DVT evaluation

Orbital/ocular ultrasound for retinal detachment/vitreous hemorrhage/ocular trauma

• Also review ultrasound guided central and peripheral IV access with the ability to practice this important technique on gel models. • Question and answer session


M edical E thics : Practical Issues and Approaches 7.5 CME credits S eparate registration required $450.00 O ne - day course : F riday , J une 28 8:00 am to 5:00 pm This course provides a solid conceptual grounding in medical ethics, while focusing on practical issues and tested approaches for resolving such issues. This course satisfies a professional development requirement for fulfilling, in part, Board recertification of the American Board of Physician Specialties of the American Association of Physician Specialists.

C ourse O bjectives Upon completion of this program participants should be able to: 1. Understand the theoretical and historical foundations of medical ethics; 2. Engage in allocation of resources decisions; 3. Apply ethical decision-making tools to actual circumstances; 4. Understand the appropriate roles of medical ethics/bioethics committees and be able to constructively contribute to these committees; 5. Recognize the stakeholders in medical ethics decisions and weigh stakeholder ethical perspectives; and 6. Guide public discussion of medical ethics issues and explain the perspectives of medical professionals on such issues.


A ccreditation S tatement The American Association of Physician Specialists, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CME C redit S tatement The American Association of Physician Specialists, Inc., designates this live activity for a maximum of 7.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

R ecertification C redit This course fulfills ABPS recertification requirements for Medical Ethics. CME credit earned for attending this course may also be applied to the CME recertification requirements.


S chedule of E vents S unday , J une 23 12 noon – 5:00 pm........ Registration Desk 1:00 pm – 5:00 pm........ Emergency Medicine Credentialing OPEN TO BOC MEMBERS/CREDENTIALING COMMITTEE ONLY 2:00 pm – 5:00 pm........ Strategic Planning Meeting

M onday - F riday

7:00 am – 5:00 pm.......... Registration 7:00 am – 8:00 am.......... Breakfast

M onday , J une 24 7:30 am – 11:30 am...... AAPS Board of Directors Meeting OPEN TO EVERYONE 7:45 am – 1:00 pm........ Auxiliary-sponsored trip to El Yunque Rainforest 8:00 am – 5:00 pm........ Examination Development Workshop I – All Specialties OPEN TO DIPLOMATES ONLY 8:00 am – 5:00 pm........ Credentialing – All Specialties OPEN TO BOC MEMBERS/CREDENTIALING COMMITTEE ONLY 11:30 am – 1:00 pm...... Lunch on your own 1:00 pm – 3:00 pm........ House of Delegates 3:00 pm – 4:15 pm........ Council of Academy Presidents Meeting 3:00 pm – 5:00 pm........ American Board of Physician Specialties (ABPS) Meeting 5:30 pm – 7:00 pm........ Welcome Reception

T uesday , J une 25 8:00 am – 9:15 am Academies of Medicine Meetings (ANESTHESIOLOGY, EMERGENCY MEDICINE, FAMILY PRACTICE, INTERNAL MEDICINE, ORTHOPEDIC SURGERY, RADIOLOGY, SURGERY) 8:00 am – 9:15 am Boards of Certification Meetings (FAMILY MEDICINE OB, URGENT CARE) 9:00 am – 11:00 am...... Auxiliary Brunch and Meeting 9:30 am – 11:00am Boards of Certification Meetings (ANESTHESIOLOGY, EMERGENCY MEDICINE, FAMILY PRACTICE, INTERNAL MEDICINE, ORTHOPEDIC SURGERY, RADIOLOGY, SURGERY)


11:00 am – 12 noon...... Membership Committee Meeting 11:00 am – 12 noon...... Governmental Affairs Committee Meeting 11:00 am – 12:30 pm.... Academy & Board Orientation 12:00 noon – 1:00 pm... Lunch on your own 12:00 noon – 5:00 pm... Examination Development Workshop II OPEN TO DIPLOMATES ONLY 1:00 pm – 2:15 pm........ American Academy of Specialists in Dermatology American Academy of Disaster Medicine 1:00 pm – 2:30 pm........ American Board of Hospital Medicine 1:15 pm – 2:30 pm........ CME Committee Meeting 2:30 pm – 3:45 pm........ AJCM Editorial Board Meeting 2:30 pm – 4 :00pm........ Board of Certification in Dermatology American Board of Disaster Medicine AAPS Foundation 4:00 pm – 5:15 pm........ Past Presidents Meeting 6:15 pm – 7:00 pm........ President’s Reception 7:00 pm – 10:00 pm...... President’s Awards Dinner

W ednesday , J une 26 8:00 am – 5:00 pm........ Bedside Ultrasound Workshop OPEN TO DIPLOMATES ONLY 8:00 am – 5:30 pm........ CME Scientific Presentations 12:00 noon – 1:00 pm... Bedside Ultrasound Lunch 12:00 noon – 1:30 pm... CME Lunch

T hursday , J une 27 8:00 am – 5:00 pm........ CME Scientific Presentations 12:00 noon – 1:00 pm... CME Lunch

F riday , J une 28 8:00 am – 5:00 pm........ Medical Ethics Course 8:00 am – 5:00 pm........ Bedside Ultrasound Workshop 12:00 noon – 1:00 pm... Bedside Ultrasound Lunch 12:30 pm – 1:30 pm...... Medical Ethics Lunch All meetings and events are open to all attendees unless noted otherwise on the schedule. Schedule is subject to change beyond the control of AAPS.


S peakers M uhammad A. A hmed , M.D. There is a Medical App for That

L ingappa S. A mernath , M.D.

New Technology Improving Patient Safety

A rthur L. B erman , D.O., FAAIM

Preventing Transmission of Hepatitis B and C in Healthcare Providers

P aul B lando , M.D.

Accurate Measurement of O2 Saturation in Acute Acquired Methemoglobinemia (AAM)

J oseph M. D amiani , M.D., FAAPRS Code Pink Infant Abduction

J ack V. G reiner , D.O., P h D, FAASS Preserving the Ocular Surface’s Role as a Barrier to Infection

S urinder K. K ad , M.D., FAAIM, MPH, MBA The Fen-Phen Debacle

A my K aleka

Screening for Psychosocial Stressors in Pregnant Patients: Are There Improved Maternal and Child Outcomes?

O mofolasade B. K osoko -L asaki , M.D.

Domestic Violence and its Ocular Manifestations

J ames M organ K yle , M.D.

Sports Concussion Management – Safe Return to Play


S peakers M ark T. L oafman , M.D., MPH

Integrated Medication Management: Moving Beyond Medication Reconciliation . . . Preparing for Obstetrical Hemorrhage . . .

L eslie M ukau , M.D., FAAEP, FACEP

Applying Lean Methodology and Current Best Practices to Emergency Department Operations . . . Reducing Risk of Radiation Exposure from Computed Tomography: New Perspectives in Improving Patient Safety

M ark P astin , P h .D. Risk and Responsibility

M adonna R ingswald , D.O., FAAIM

Teach-Back Method: Preventing Readmissions and Medication Errors

E duardo S cholcoff , M.D.

Pregnant Trauma in the ER: New Tools for Better Outcomes

J ames W. T erbush , M.D., MPH

Health Consequences of a Cyber Event: A Real Risk to Patient Safety

D aniel Y. W ang , M.D.

How Does Medical Board Investigate If Being Sued?


A ccommodations C onrad S an J uan C ondado P laza offers guests a breathtaking beachfront location - the ideal setting for an island getaway with endless choices in entertainment and relaxation.

Located close to the airport and within minutes of the historic heart of the island’s capital

999 Ashford Ave. San Juan, PR 00907 Hotel Direct: 787-721-1000 | Reservations Direct: 787-721-1000 X 2030 and 2031 Hilton Reservations: 800-HILTONS | Fax: 787-722-7955 Group code: ACMZ

www.condadoplaza.com

H otel R eservations AAPS has a limited number of rooms available at this rate so we encourage you to make your reservations now. The group rate will be available until MAY 30, 2013, OR until the group block is sold out, whichever comes first. NOTE: Please let the AAPS Meetings Department know if you do not make your reservation directly with the hotel – either through the hotel website or hotel reservations. Reservations made outside of this method will be counted toward our hotel room obligation – if you let us know you have made them. • Single or double occupancy $159 (approximately $207 including all taxes) • Children in same room with parents: Free • Guaranteed room rate applies three days before and three days after meeting, based on availability at the time of the request. • Check-in 4:00 pm | Check-out 12:00 noon • Hotel cancellations must be made 72 hours prior to day of arrival to avoid cancellation fee. Any problems making hotel reservations, call the AAPS Meetings Department immediately.


H otel A menities

B each /P ool Refresh your senses in the shimmering waters of Puerto Rico.

With three outdoor pools, whirlpool, and a magnificent beachfront, you will be captivated by unbelievable views and surprising indulgences. Immerse yourself in the comfort of the saltwater pool or enjoy a workout in the lap and lounging Lagoon Pool.

W ater S ports Features kayak and stand-up paddle board rentals, snorkeling. T he F itness C enter Keep your workout routine in the state-of-the-art Fitness Center, featuring sauna and steam room - open 24 hours.

S pa Nearby – Zen Spa –

www.zen-spa.com and Olas Spa at the Caribe Hilton Hotel.

G ames Join in the fun of

the daily activities program. Table games, balls and other recreational toys are available on request.

T ennis C ourts Test your skill

on the hotel’s two lighted tennis courts. Lessons are available.

G olf See Dorado Beach at www.doradobeachclubs.com. C asino Play a hand of blackjack in the 24-hour Condado Casino. R estaurants Five onsite restaurants, three lobby bars.


N earby A ttractions & S hopping Puerto Rico is known for its stunning beaches, extraordinary landscapes, friendly people, delectable dining, and exciting nightlife and gaming. The Conrad San Juan Condado Plaza is within minutes of the historic heart of the island’s capital. Old San Juan has a high concentration of museums, stores, and art galleries. Take a step back in time as you stroll along historic cobblestone streets and admire the colonial architecture. Browse the high-end shops – just minutes from your door. Be sure to visit the Bacardi Rum Distillery, Pablo Casals Museum, the El Morro Fortress, and the Pharmacy Museum.

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limate and lothing Be prepared for hot days and cool nights 82° days and 78° nights. Check local listings to determine weather conditions. Casual clothing is recommended both in and out of the meeting rooms with the exception of the President’s dinner when a jacket and tie for men (black tie is optional) and corresponding attire for women is requested. You may want to bring clothing to accommodate all meeting room temperatures.

H elpful W ebsite www.enjoypuertorico.com T ravel I nformation A irport : Luis Munoz Marin (SJU) is located

approximately seven miles and 15 minutes from the hotel.

A irport T ransportation :

Transportation to the hotel is available in the airport shuttle area. Taxis are approximately $15 + luggage and gratuity.

H otel P arking : Valet parking $20 plus tax per day. Self-parking $15 plus tax per day.

S pecial AAPS – H ertz R ental R ate : You can make reservations

online at Hertz.com or call Hertz directly at 800-654-2240. Use AAPS code CV# 04SW0002. Meeting rate is guaranteed from one week prior through one week after the meeting dates and is subject to availability.


D ear A uxiliary M embers and G uests : Welcome to the 2013 AAPS Annual Meeting. I hope you will join us at the luxurious Conrad San Juan Condado Plaza for some fun and sun as we relax poolside, try one of several on-site restaurants, or try your luck at San Juan’s largest 24-hour casino, located within the hotel. Join us on Monday, June 24, for an exciting ½ day walking tour (7:45 am to 1 pm) of the El Yunque Rainforest. This activity is free for all current Auxiliary members and their immediate family members (children and grandchildren 18 year of age and younger and spouse/ significant other). For guests not currently active Auxiliary members, admission is $59 per person, including your transportation and admission to the tour. Advance Registration is required. You can sign up on the Registration Form in this brochure. Bring your camera, comfortable shoes, and a hat. Monday evening is the Auxiliary-sponsored Welcome Reception with a Latin theme. Everyone is welcome to attend the Auxiliary’s annual brunch at 9 am on Tuesday followed by a brief business meeting. Renew old acquaintances, build new friendships, encourage your spouse, and support the AAPS Foundation. Make the AAPS Annual Scientific Meeting a family vacation event! Hope to see you there!

Linda Russo

President AAPS Auxiliary

AAPS A uxiliary • Open to all family members • Auxiliary dues are $60 per year • Auxiliary-sponsored half-day trip to El Yunque Rainforest Monday, June 24 – meet in lobby at 7:45 am • Welcome Reception Monday, June 24, 5:30 – 7 pm, sponsored by the AAPS Auxiliary • Annual Auxiliary Meeting and Brunch Tuesday, June 25, at 9 am


I mportant R egistration I nformation 1. To be officially registered, all fees must be paid in full prior to the appropriate deadlines: Early Registration by March 22, 2013, or Still-Time-Register by May 31, 2013. 2. All registrations received after May 31, 2013, including On-Site, must be paid in full prior to admission to any AAPS activities. Late/On-Site Registration will be accepted by CREDIT CARD ONLY. 3. There are no exceptions to the fees and deadlines. 4. No one will be admitted to any business sessions, CME sessions, breakfast, lunch, or President’s Awards Dinner without a valid badge. There are four member categories:

There are two registration packages:

DIPLOMATE/EMERITUS/MEMBER PRESENTER AAPS RETIRED NON-MEMBER CME ONLY

There are three registration deadlines: EARLY REGISTRATION – BY MARCH 22, 2013 STILL-TIME-TO-REGISTER – BY MAY 31, 2013

There are two Bedside Ultrasound Workshops:

BUSINESS/GOVERNANCE ONLY CME/EDUCATION ONLY

There is one Medical Ethics course:

LATE/ON-SITE REGISTRATION – AFTER MAY 31, 2013

FRIDAY, JUNE 28, 2013

WEDNESDAY, JUNE 26, 2013 FRIDAY, JUNE 28, 2013

TWO REGISTRATION PACKAGES

BUSINESS: Includes all meetings – Board of Directors, Academies of Medicine,

Boards of Certification, House of Delegates, Committees, Examination Development Workshops (up to 12 CME credits) and any other scheduled business meetings; conference materials; and breakfast on Monday, June 24, and Tuesday, June 25. Two days – see pricing on registration form.

CME: Includes up to 16 CME credits for scientific presentations, conference materials, breakfast, and lunch on Wednesday, June 26, and Thursday, June 27. Two days – see pricing on registration form. ADDITIONAL OPTIONS

WELCOME RECEPTION ON JUNE 24: All tickets are free – sponsored by the AAPS Auxiliary. However, you must register in order to save your place. PRESIDENT’S DINNER ON JUNE 25: Per ticket $125. BEDSIDE ULTRASOUND WORKSHOP: Includes one-day course on Wednesday, June 26, or Friday, June 28, course materials, up to 7.75 CME credits, breakfast, and lunch. One-day-course – $799. MEDICAL ETHICS: Includes one-day course on Friday, June 28, course materials, up to 7.5 CME credits, breakfast, and lunch. One-day-course – $450.


R egistration I nformation All attendees MUST REGISTER for the 2013 House of Delegates and Annual Scientific Meeting in order to attend any sessions including business meetings, continuing medical education activities, and/or certification examination development workshops. To complete registration for the 2013 Annual Meeting, ALL FEES MUST BE PAID IN FULL IN ADVANCE. See Registration Form for specific information. Every effort will be made to ensure that the published schedule, as stated in the brochures, will be followed. However, changes beyond AAPS control may occur. AAPS is not responsible for notifying registrants of program changes prior to the meeting.

CONFIRMATION OF REGISTRATION: A confirmation packet will be mailed within two (2) weeks of receipt of your registration form and PAID IN FULL

registration fees. Please retain copies of your registration information. If you do not receive a confirmation packet within two weeks, please contact the AAPS Meetings Department immediately.

MEETING ATTENDANCE AND CANCELLATION POLICY: ALL PERSONS ATTENDING AAPS MEETINGS ARE REQUIRED TO REGISTER AND PAY THE APPROPRIATE REGISTRATION FEE IN ADVANCE REGARDLESS OF PURPOSE OR THE NUMBER OF MEETINGS ATTENDED.

Written cancellations must be received by the AAPS Meetings Department prior to April 15, 2013, in order to receive a full refund of Meeting Registration Fees, less a $150 processing fee. Cancellations received after this date will not be accepted.

PRESENTER DISCLOSURE: The American Association of Physician

Specialists, Inc., believes in full disclosure. Each presenter or sponsor is required to disclose real or apparent conflicts of interest relating to topics of this educational activity. Presenter disclosure will be made to all participants in the educational activity materials and at the beginning of each presentation.


REGISTRATION FORM: AAPS 2013 HOUSE OF DELEGATES AND ANNUAL SCIENTIFIC MEETING

TO REGISTER BY FAX: 813-830-6599 (CREDIT CARD ONLY) • MAIL: AAPS, 5550 W. EXECUTIVE DRIVE, SUITE 400, TAMPA, FL 33609-1035 Name________________________________________________________________Email Address: _____________________________________________________ Address_____________________________________________________ City_____________________________ State______________Zip_____________________ Home phone________________________________ Work phone____________________________________ Cell phone____________________________________

TO COMPLETE THE REGISTRATION FORM DO THE FOLLOWING: 1. Review Important Registration Information. 2. Select one of three registration packages (Business, CME, Discount Package). 3. Select from Additional Options (Medical Ethics Course, Bedside Ultrasound Workshop, Auxiliary-Sponsored Rainforest Tour, Welcome Reception, President’s Dinner). 4. Review registration table on right and circle your registration choice. Enter fee amount in subtotal.

Member Type AAPS Diplomate/ Emeritus/Member Presenter REGISTRATION REQUIRED BY JAN. 31, 2013 AAPS Retired Non-Member

Registration Packages

Early Registration

Not Available

Still-Time-To Register By May 31, 2013

Late/On-Site After May 31, 2013

Business Package

$495

$695

CME Package

$725

$925

Business Package

NA

NA

CME Package

NA

NA

Business Package

$495

$695

CME Package

$525

$725

CME Package

$850

$1050

Packages Total $____________

MEDICAL ETHICS COURSE - FRIDAY, JUNE 28..........$ 450 per person x _____ (# attending) =

Medical Ethics Registration Total $____________

BEDSIDE ULTRASOUND WORKSHOP - Select one course from below.   COURSE 1 - WEDNESDAY, JUNE 26 ................. $ 799 per person x _____ (# attending) =  COURSE 2 - FRIDAY, JUNE 28 ........................... $ 799 per person x _____ (# attending) = Ultrasound Workshop Registration Total $____________

NO ONE WILL BE ADMITTED TO ANY SESSIONS INCLUDING MEALS WITHOUT A VALID BADGE AUXILIARY RAINFOREST TOUR – MONDAY, JUNE 24 - Select from below. See AAPS Auxiliary Page for more information.  Complimentary Registration for PAID Auxiliary Members $ 0 per person x _____ (# attending) = $0.00  Non-Complimentary (Paid) Registration for Non-Members $ 59 per person x _____ (# attending) = Auxiliary Rainforest Tour Total $____________ $0.00 WELCOME RECEPTION - MONDAY, JUNE 24.....................................$ 0 per person x _____ (# tickets) = Welcome Reception Total $____________

(Complimentary, but you must register)

PRESIDENT’S AWARDS DINNER - TUESDAY, JUNE 25.................. $ 125 per person x ____ (# tickets) = MEETING REGISTRATION PAYMENT  Check enclosed

 American Express  MasterCard

President’s Dinner Total $___________  Visa

Grand Total to be charged: $

Cardholder’s Name_________________________________________________Card Number _______________________________ Expiration Date________________ Cardholder’s Mailing Address_____________________________________________________ Cardholder’s Signature_______________________________________

ALL PARTICIPANTS MUST COMPLETE DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS BELOW  I DO NOT have a relevant financial relationship with a commercial interest. Signature ___________________________________________________________________________ Date __________________________  I DO have a relevant financial relationship with a commercial interest. (You MUST list relevant financial relationships below.) Signature ___________________________________________________________________________ Date __________________________ First, list the names of proprietary entities producing health care goods or services, consumed by, or used on, patients, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours. 1. Commercial Interest (Example: Company ‘X’)

Second, describe what you or your spouse/partner received (ex: salary, honorarium etc). The American Association of Physician Specialists, Inc. does NOT want to know how much you received. Third, Describe your role.

Nature of Relevant Financial Relationship (Include all those that apply) 2. What was received (Example: Honorarium)

3. For what role? (Example: Speaker)

Example Terminology

What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, Role(s): Employment, management position, independent contractor (including contracted research), ownership interest (e.g., stocks, stock options or other ownership interest, excluding consulting, speaking and teaching, membership on advisory committees or review panels, board diversified mutual funds), or other financial benefit. membership, and other activities (please specify). Glossary of Terms

Commercial Interest: The ACCME defines a “commercial interest” as any proprietary entity producing health care goods or services, used on, or consumed by, patients, with the exemption of non-profit or government organizations and non-health care related companies. Financial relationships: Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

Relevant financial relationships: ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.


asmbrochure2013