Host a Visiting Professorship Program Earn up to 4 complimentary CME/CE credits

CME/CE Activity Request Form

 

Initiating a Program

The request must be initiated by a medical center and a contact person must be designated. This individual will be the primary contact for all communications with ACHL. The final agenda and visiting faculty selection will be discussed with the program requestor.

 

Program Requestor

Name* Title
Institution* Address*
City* State*
Zip* Office Phone*
  Ext 
Office Fax Cell Phone
E-mail*

Name of Primary Contact or Assistant

Same As Above
Name* Title
Contact Phone* Contact Fax
Contact E-mail*    

Preferred Date & Time (January 2013 - December 2013)

First Choice* Second Choice
Third Choice    

Faculty Preference (Click to view faculty)

Multiple Sclerosis Visiting Faculty
Patricia K. Coyle, MD
Professor
Department of Neurology
SUNY at Stony Brook
Stony Brook, NY
Khurram Bashir, MD, MPH
Professor and Vice Chair for Education
Director, Division of Neuroimmunology and Multiple Sclerosis
Director, Multiple Sclerosis Center
Director, Neurology Residency Training Program
UAB School of Medicine
Birmingham, AL
Guy J. Buckle, MD
Assistant Professor of Neurology
Harvard Medical School
Director, MS Clinical Care
Partners MS Center
Brigham and Women’s Hospital
Boston, MA
Clyde E. Markowitz, MD
Director
Multiple Sclerosis Center
University of Pennsylvania
Associate Professor of Neurology
Philadelphia, PA
Robert T. Naismith, MD
Assistant Professor
Department of Neurology
Washington University School of Medicine
St. Louis, MO
Amy Perrin Ross, APRN, MSN, CNRN, MSCN
Neuroscience Program Coordinator
Loyola University Medical Center
MS Center
Maywood, IL
Ben W. Thrower, MD
Medical Director
MS Institute Shepherd Center
Medical Director, Intestinal Rehabilitation Program
Clinical Instructor of Neurology
Emory University
Atlanta, GA
First Choice* Second Choice
Third Choice    

Please Indicate Higher Priority


Expected Number Of Participants

Physicians Nurses
Case Managers Other