Help
EMAs in shortfall for continuing competence requirements should complete this form to request adjudication. Please make sure that you submit your supporting documentation along with the form.
Lease
Renew lease?

Licensee Information

Missing or incorrect value
Missing or incorrect value
Missing or incorrect value
Missing or incorrect value
Missing or incorrect value
Missing or incorrect value

Summary of Adjudication Request

Outline the details of the course content and what skills and/or knowledge were obtained from the continuing education activity submitted for adjudication below.

  • Include the course provider, name of activity, date, duration, location, and certificate of completion.
  • If submitting a conference, include a copy of the agenda with the breakdown of sessions and their content, and your verification of attendance.
  • For patient contacts, please provide the date, location, your role, patient chief complaint or type of contact, and the skills performed for the patient for each contact submitted.
Missing or incorrect value

Attach Your Supporting Documentation

Attach all of your supporting documentation
Drag files here or select files.
Remove File
Missing or incorrect value

HLTH 3735  Rev. 2023/01/18
Current Date

b13537a5b0c227c399606133c09c9210b1817afc
Confirm
Form Submitted
Review Form Validation Messages
Unable to complete action
Confirmation
Confirmation
Create link to share
Session About To ExpireSession Expired
Your session is about to expire. Click the button below if you wish to continue using this page.
Your session has expired.