2018 Program for Distressed Physicians Enrollment Form
Vanderbilt University Medical Center is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical Education for physicians.

Target Audience: Physicians whose workplace behavior has become problematic.

You may pay online with your Credit Card for the three day course and three one day follow-up sessions (fee includes continental breakfast, lunches, and CME fees - $4525). If paid by check the cost is $4500. A  deposit of $300 is required to reserve a space in the course. The balance of the fee ($4200) may be paid on the first day of the course during registration. Please make checks payable to "VUMC."

Course enrollment is limited to 6 participants. A phone interview with William H. Swiggart, M.S. is required prior to registration. Please call 615.936.0678 to schedule.

Please complete the registration form after your interview.

Your registration confirmation will be sent by email. If you do not receive a confirmation within one business day, please check your junk or spam folders.

NAME:
SUFFIX: (E.g., MD, PhD, etc.)
NAME TAG:
SPECIALTY:
ADDRESS:/div>
CITY:
STATE:
ZIP CODE:
PHONE:
FAX:
E-MAIL:
REFERRED BY:
EMERGENCY CONTACT: Please provide name and phone # of the individual who should be contacted in case of emergency.
Name:
Phone:

Program for Distressed Physicians 2018 COURSE DATES: (Please select one)

January 10-12 (plus 3 one-day follow-up sessions over 6 months, dates TBA)

March 14-16 (plus 3 one-day follow-up sessions over 6 months, dates TBA)

June 27-29 (plus 3 one-day follow-up sessions over 6 months, dates TBA)

September 26-28 (plus 3 one-day follow-up sessions over 6 months, dates TBA)

November 7-9 (plus 3 one-day follow-up sessions over 6 months, dates TBA)

A continental breakfast and box lunch will be provided daily. If you have food allergies or dietary requests, please let us know.<

Comments:

PAYMENT OPTIONS: Credit card payments are accepted online only. If you prefer to pay by CHECK you may pay ON SITE at CPH or by MAIL (CPH, Room 1107 Oxford House, 1313 21st Avenue South, Nashville, TN 37232-4300).

ONLINE VIA CREDIT CARD  Please return to CPH main  page and click the "Online Payment" tab after you have submitted this form.

CHECK/MONEY ORDER/CASH( Payable to VUMC)

 
The daily course schedule (subject to change), goals, and objectives are available on our website.
 

Designation of Credit: Vanderbilt University Medical Center designates this educational activity for a maximum of 48.25 AMA PRA Category 1 Credits.. Physicians should only claim credit commensurate with the extent of their participation in the activity. Credit will NOT be awarded until the completion of the three follow-up sessions.

 
Faculty Disclosure:  It is the policy of Vanderbilt University Medical Center to require disclosure of financial relationships from individuals in a position to control the content of a CME activity; to identify and resolve conflicts of interest related to those relationships; and to make disclosure information available to the audience prior to the CME activity. Presenters are required to disclose discussions of unlabeled/unapproved uses of drugs or devices during their presentations.
 
All course directors, planners, and speakers indicated no financial relationships to disclose.
Cancellation Policy: If you must cancel your registration, your $300 deposit is non-refundable. Your registration may be transferred to another course date. In the event of cancellation or rescheduling of this CME activity due to unforeseen circumstances, Vanderbilt University will refund the registration fee in full. Vanderbilt University is not responsible for non-transferable, non-refundable airline tickets or hotel accommodations purchased in connection with attendance at this CME activity.
 

Course Faculty

William Swiggart, M.S.
Assistant in Medicine, Department of Medicine
Co-Director, Center for Professional Health
Vanderbilt University Medical Center

Douglas R. Herr, Psy.D.
Assistant Professor of Psychiatry
Vanderbilt Osher Center for Integrative Health
 
Ronald E. Neufeld, B.S.W., L.A.D.A.C.
Program Director

Vanderbilt Comprehensive Assessment Program for Professionals (VCAP)

Linda L.M. Worley, M.D., FAPM
Adjunct Clinical Professor of Medicine
Vanderbilt Center for Professional Health (CPH)
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Vanderbilt Center for Professional Health
E-MAIL: CPH@vanderbilt.edu

WEB SITE: ww2.mc.vanderbilt.edu/cph