eaccme_creditfrm.pdf

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* Date of birth assists in uniquely identifying physicians for purposes of credit processing.  The medical education [ME] number is an 
11-digit number assigned to every physician in the US by the AMA for identification and recording of basic information.  The ME 
number is found on the AMA membership card.  
** The processing fee is non-refundable. 
***Mandatory in order to receive certificate. 
 
Application for EACCME Credit Conversion   
 
The European Accreditation Council for Continuing Medical Education (EACCME) is an institution of the 
European Union of Medical Specialists (UEMS).  EACCME approved credits for live activities are recognized 
by the American Medical Association for conversion to AMA PRA Category 1 Credit™ (a list can be found at 
www.uems.net).  Physicians may apply to convert EACCME credit into AMA PRA Category 1 Credit™ by 
submitting this form and attaching an EACCME credit certificate, and processing fee.  A certificate of AMA 
PRA Category 1 Credit™ will be mailed within 4 weeks. 
 
(Please print) 
Physician Name: 
 
Full Name of Conference: 
 
 
Conference Date & Location: 
 
Total number of credits claimed: 
 
 
Name/Degrees: 
 
Title: 
 
Institution: 
 
Specialty: 
 
Address: 
 
City: 
 
State: 
 
Zip: 
 
Telephone: 
 
Email Address:*** 
 
Date of Birth:* 
 
Medical Education Number (optional):* 
 
 
Processing Fees**: 
 AMA Member $30 
 Non-AMA Member $75 
 Check enclosed (please make checks payable to the American Medical Association) 
 Credit Card 
 American Express 
 Visa 
 Master Card 
 Optima 
Name as it appears on the card: 
 
Account Number: 
 
Expiration Date: 
 
Signature: 
 
 
 
 
Please mail or fax this form, along with your EACCME credit certificate, to the American Medical 
Association, CPPD, 515 North State Street, 7th Floor, Chicago, IL 60654.  
FAX:  312-464-5129.  Any questions or concerns, call 312-464-5296.