(P) 606-218-5413 • (F) 606-218-5168www.upike.edu

Registration FormPlease print clearly. Return in provided envelope

no later than September 1.

Name __________________________________________________

AOA Number ___________________________________________

Address ________________________________________________

_______________________________________________________

City _________________ State __________ ZIP _____________

KYCOM Alumni Class of ________ Fax ______________________

Phone (Work) _________________ (Cell) ____________________

Phone (Home) ________________ Email ____________________

Meeting FeesPlease check the events you plan to attend and

indicate the fees included in your total payment.

______ KYCOM Primary Care CME Program $______________

Early Registration$350 per person if received by September 1

$425 if received after September 1

_____ Registered Nurse $50

_____ Physician Assistant $50

_____ I will attend Founders Dinner. (No Cost) _____ # Tickets Needed for Founders Dinner

KYCOM Alumni ReceptionSaturday, September 14, 6 p.m. – 8 p.m.

Green Meadow Country Club_____ # Tickets needed (No Cost)

Registration Payment ☐ Enclosed is check # _____ in the amount of $ ________

☐ Charge $ ___________ to my credit card: ☐ Master Card ☐ Visa ☐ Discover

Note: There will be a 2.7% usage fee on all credit card charges.

Name __________________________________________________

Credit Card Number ________ - ________ - ________ -________

Security Code:____________________ Exp. Date: _____________

Name on Card: __________________________________________

Address of Cardholder ____________________________________ Street

City _________________ State __________ ZIP _____________

Cardholder Phone Number: ________________________________

Total Amount Charged: $ _______________ (+ 2.7% usage fee)

Signature _____________________________________________

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Primary Care Continuing Medical Education and Alumni Weekend

Contemporary Issues in Practice Management

September 13-15, 2019

147 Sycamore StreetPikeville, KY 41501

Friday-SaturdayHealth Professions Education Building7th Floor Pavilion

SundayCoal Building

9th Floor OPP Lab

RegistrationPlease complete the registration form and return no

later than September 1 to: Deean Skeens, Director

Continuing Medical Education University of Pikeville

Kentucky College of Osteopathic Medicine147 Sycamore StreetPikeville, KY 41501

DeeanSkeens@upike.eduFax: (606) 218-5168

Early RegistrationRegistration fees are $350 per person if received by September 1 and $425 if received after September 1. Founders Dinner is included. Registered Nurses (RN) and Physicians Assistants (PA) fees are $50

per person.

CancellationsKYCOM must be notified of cancellations in writing by September 1 in order to provide a refund. A $50 processing fee will be assessed on all refunds prior to September 1. Cancellations received after September 1 will not be refunded.

For more information, contact Deean Skeens, Director

Continuing Medical Education University of Pikeville

Kentucky College of Osteopathic Medicine(606) 218-5413

DeeanSkeens@upike.eduFax: (606) 218-5168

Special EventsFriday, September 13

Founders Dinner andJohn A. Strosnider Memorial Lecture

Reception followed by dinner

Keynote Speaker:Steven R. Harris, Ph.D.

Kentucky College of Osteopathic MedicineFormer Associate Dean of Academic Affairs (1998-2018)

6 p.m.F.A. Bailey Room, Hilton Garden Inn

849 Hambley Blvd., Pikeville, KY 41501

Saturday, September 14

KYCOM Alumni Reception 6 p.m. – 8 p.m.

Green Meadow Country Club6887 North Mayo Trail

Pikeville, KY 41501

AccommodationsA block of rooms has been reserved

at the Hampton Inn.831 Hambley Blvd.Pikeville, KY 41501

(606) 432-8181

Accommodations can be made at the Hampton Inn with a rate of $110 per night if booking before

September 1. Use code “CME19” whenreserving your room.

General Meeting InformationMeeting Hours:

Friday, September 13: 8 a.m. - 5:15 p.m. Saturday, September 14: 8 a.m. - 4:30 p.m.

Sunday, September 15: 8 a.m. - 12 p.m.

This program is anticipated to offer 20 hours of AOA Category 1-A CME credit, pending the approval of the AOA Council on Continuing Medical Education. The Southeastern Kentucky AHEC designates this educational activity for a maximum of 20 PRA Category 1 Credit(s). AAFP accreditation has been applied for.

Program Theme: Contemporary Issues in Practice

ManagementThis Primary Care CME program will offer a comprehensive review of “Contemporary Issues in Practice Management.” Friday and Saturday sessions will include updates in Family Medicine, Infectious Diseases, Neurology and Issues on the Opioid Crisis in Eastern Kentucky. The Sunday morning session will be devoted to hands-on OMT technique workshops taught by KYCOM faculty and alumni.

Note: The event presentations will be paperless and accessible via Dropbox application at the CME event.

Access and log in information to the event presentations will be made available upon check-in at the event.