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Page 1: SOUTHWEST Ohio REGIONAL UPDATE IN INTERNAL …aipcincinnati.org/wp-content/uploads/2017/02/SWOHIM2017-brochure-2-3-17.pdfSOUTHWEST OHIO REGOINAL UPDATE IN INTERNAL MEDICINE 2017 The

SOUTHWEST Ohio REGIONAL UPDATE IN

INTERNAL MEDICINE 2017

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SOUTHWEST OHIO REGOINAL UPDATE IN INTERNAL MEDICINE 2017

The Southwest Ohio Regional Update in Internal Medicine is a medicine board review course that will provide an intensive review of medicine for physicians preparing for the ABIM initial and recertification examinations. The course will also allow an in-depth review with recent updates for physicians practicing internal medicine and other disciplines, providing continuing medical education and maintenance of certification credit.

Course content is based on the blueprint for certification and recertification examinations. The course comprises of didactic lectures with multiple questions, case-based discussions, and interactive Self Evaluation Process (SEP) modules. Attendees will be provided with detailed course material along with expert specialty questions and answers for thorough independent examination preparation.

The registration fee includes course tuition, meals and beverages during scheduled date of course, and electronic resources and course materials including board review study guides that can be accessed for defined period of time past the board examination.

We try to make it our policy to not limit the number of registrants for conferences, but conference facilities may necessitate closing enrollment, early registration is advised. All completed registrations online will receive an immediate confirmation.

Cancellation PolicyCancellation of your participation in the course, your paid registration fee, less a $50 administrative fee, will be refunded when written notification is recieved before March 17, 2017 at [email protected]. No refund will be made on or after March 17, 2017. Canceled registrations are non-transferable.

Lodging/AccommodationsSpecial course rates have been arranged at hotels identified below. These hotels are located within a few miles of the conference location (Manor House, Mason, Ohio). In order to receive the special rate, reservations need to be made by March 1, 2017. Please identify that you are attending the Southwest Ohio Regional Update in Internal Medicine Conference.

Springhill Suites Northeast/Mason9365 Waterstone Blvd, Cincinnati, OH 45249Ph. 513-683-7797

Hyatt Place Cincinnati Northeast5070 Natorp Blvd, Mason, OH 45040

Ph. 513-754-0003

WeekendsMarch 31-April 1April 7-April 8April 21-April 22April 28-April 29May 5 -May 6

Manor House7440 S Mason-Montgomery Road Mason, Ohio 45040

Fee includes continental breakfast, refreshment breaks, lunches, and course CMEs and/or MOCs.

RegistrationRegistration for the course is required to be completed online at: https://www.regonline.com/SWOhioIM2017

Residents and trainees registration for a discounted rate will need to submit a letter from a program director to receive the resident/fellow fee. If a letter is not received within 10 business days of registration submission, the full physician fee will be charged. Alternatively, program staff can register trainees online.

*New and Returning Members to Academy of Medicine of Cincinnati~ Can only be $250 once as trainee, cannot be a member

Course Fee Academy Member

Physician, Clinical Staff-Full Course

$475 $300 ($99*)

Physician, Clinical Staff-Weekend Course

$150 $75

Physician, Clinical Staff-Friday Only

$50 $25

Physician, Clinical Staff-Saturday Only

$80 $40

Resident/Subspecialty Fellow/ Trainee-Full Course

$250 ~$250

Course Learning Objectives: • Utilize evidence-based medicine principles as a basis to answer clinical questions.

• Apply current concepts in internal medicine to problems faced in daily practice.

• Discover personal strengths and weaknesses for focused self- study in preparation for certification/recertification exam.

This board review has a unique format of being offered over 5 weekends and will cover 2-3 major specialty areas each weekend. Registration will include a comprehensive package as well as an “a la carte” option which will allow participation in the full course or selected specific sessions.

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Topic Breakdown:

• Endocrinology• Gastroenterology• Geriatrics• Dermatology• Psychiatry• Cardiology• Critical Care• Neurology• Statistics/Epidemiology• Nephrology• Rheumatology• Infectious Disease• Pulmonary• Hematology• Oncology• Palliative Care• SEP Modules• Update Internal Medicine

Weekend Format*

Fridays:1:30 p.m. Registration 2:00-4:00 p.m. Presentations4:00-4:15 p.m. Break (Snacks)4:15-6:15 p.m. Presentations6:15-7:00 p.m. Board Simulation Examination

Saturdays:7:30-8:00 a.m. Registration/Continental Breakfast8:00-10:00 a.m. Presentations10:00-10:15 a.m. Break10:15-12:15 p.m. Presentations12:15-1:00 p.m. Lunch1:00-3:00 p.m. Presentations3:00-3:15 p.m. Break3:15-5:15 p.m. Presentations5:15-6:00 p.m. Board Simulation Examination

*5th Weekend SEP Modules

Completing CME Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 60 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. The University of Cincinnati designates this live activity for a maximum of 60 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity. The University of Cincinnati is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

According to the disclosure policy of the University of Cincinnati College of Medicine, all faculty, planning committee members and other individuals who are in a position to control content are required to disclose any relevant relationships with any commercial interest related to this activity. The existence of these interests or relationships is not viewed as implying bias or decreasing the value of the presentation. All educational materials are reviewed for fair balance, scientific objectivity and levels of evidence. Disclosures will be made at the time of the activity.

Course Directors:Gregory Rouan, MDGordon and Helen Hughes Taylor Professor of MedicineChair of Internal MedicineUniversity of Cincinnati, Department of Internal Medicine

Alexandru Costea, MDProfessor of Clinical MedicineDivision of Cardiovascular Health and DiseaseUniversity of Cincinnati, Department of Internal Medicine

Ganesh Yadlapalli, MDProfessor of MedicineDivision of Nephrology and HypertensionUniversity of Cincinnati, Department of Internal Medicine

Eva Meunier, BSEducation Program ManagerDivision of Cardiovascular Health and DiseaseUniversity of Cincinnati, Department of Internal Medicine

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Conference Schedule

Friday March 31, 2017

Rheumatology Moderator: Surabhi Khanna, MD Assistant Professor of Clinical Medicine Division of Immunology, Allergy and Rheumatology University of Cincinnati College of Medicine

Systematic Lupus Erythematosus Rina Mina, MD Assistant Professor of Clinical Medicine Division of Immunology, Allergy and Rheumatology University of Cincinnati College of Medicine

Vasculitis Priyanka Vashisht, MD Adjunct Assistant Professor of Clinical Medicine Division of Immunology, Allergy and Rheumatology University of Cincinnati College of Medicine

Idiopathic Inflammatory Myositis John Houk, MD Professor of Medicine Division of Immunology, Allergy and Rheumatology University of Cincinnati College of Medicine

Rheumatoid Arthritis Guarav Gulati, MD Assistant Professor of Clinical Medicine Division of Immunology, Allergy and Rheumatology University of Cincinnati College of Medicine

Crystalline Arthritis Priyanka Vashisht, MD Assistant Professor of Clinical Medicine Division of Immunology, Allergy and Rheumatology University of Cincinnati College of Medicine

Seronegative Spondyloarthritis Avis Ware, MD Professor of Clinical Medicine Division of Immunology, Allergy and Rheumatology University of Cincinnati College of Medicine

Systemic Sclerosis Surabhi Khanna, MD Assistant Professor of Clinical Medicine Division of Immunology, Allergy and Rheumatology University of Cincinnati College of Medicine

Saturday April 1, 2017

Gastroenterology Moderator: Michael Schoech, MD Assistant Professor of Clinical Medicine Division of Digestive Diseases University of Cincinnati College of Medicine

Esophageal Diseases Jon Kushner, MD Associate Professor of Clinical Medicine Division of Digestive Diseases University of Cincinnati College of Medicine

Colon Cancer Vidhya Kunnathur, MD Assistant Professor of Clinical Medicine Division of Digestive Diseases University of Cincinnati College of Medicine

Diarrhea and Malabsorption Ralph Giannella, MD Professor Emeritus Division of Digestive Diseases University of Cincinnati College of Medicine

Inflammatory Bowel Disease Vidhya Kunnathur, MD Assistant Professor of Clinical Medicine Division of Digestive Diseases University of Cincinnati College of Medicine

Pancreatic Diseases Sampath Poreddy, MD Assistant Professor of Clinical Medicine Division of Digestive Diseases University of Cincinnati College of Medicine

Liver Diseases Michael Schoech, MD Assistant Professor of Clinical Medicine Division of Digestive Diseases University of Cincinnati College of Medicine

Neurology Moderator: Robert Neel, MD Professor of Medicine Vice Chair of Education Department of Neurology and Rehabilitation Medicine University of Cincinnati College of Medicine

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Friday April 7, 2017

Pulmonary Co-Moderators: Jean Elwing, MD Associate Professor of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine University of Cincinnati College of Medicine

Peter Lenz MD Associate Professor of Medicine Fellowship Director, Pulmonary and Critical Care Division of Pulmonary, Critical Care, and Sleep Medicine University of Cincinnati College of Medicine

Chronic Obstructive Pulmonary Disease Ralph Panos, MD Professor of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine University of Cincinnati College of Medicine Chief of Medicine, Cincinnati VA Medical Center

Asthma Peter Lenz MD Associate Professor of Medicine Fellowship Director, Pulmonary and Critical Care Division of Pulmonary, Critical Care, and Sleep Medicine University of Cincinnati College of Medicine

Venous Thrombosis and Pulmonary Embolism

Amaresh Nath, MD Pulmonologist Atrium Medical Center Middletown, Ohio

Pulmonary Physiology and Pulmonary Function Tests

Adam Cole, MD Assistant Professor of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine University of Cincinnati College of Medicine

Pulmonary Arterial Hypertension Jean Elwing, MD Associate Professor of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine University of Cincinnati College of Medicine

Pleural Disease and Lung Cancer Pearls Rick Balestra,, MD Assistant Professor of Clinical Medicine Division of Pulmonary, Critical Care, and Sleep Medicine University of Cincinnati College of Medicine

Interstitial Lung Disease Nishant Gupta, MD Adjunct Assistant Professor of Clinical Medicine Division of Pulmonary, Critical Care, and Sleep Medicine University of Cincinnati College of Medicine

Critical Care-Sepsis and Respiratory Failure Veronica Indihar, MD Assistant Professor of Clinical Medicine Division of Pulmonary, Critical Care, and Sleep Medicine University of Cincinnati College of Medicine

Sleep Medicine Ann Romaker, MD Associate Professor of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine Director, University of Cincinnati Medical Center Sleep Center University of Cincinnati College of Medicine

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Saturday April 8, 2017

Oncology Moderator: Tahir Latif, MD Associate Professor of Medicine Director, Division of Hematology Oncology University of Cincinnati College of Medicine

Breast Cancer Mahmoud Charif, MD Associate Professor of Medicine Division of Hematology & Oncology University of Cincinnati College of Medicine

Lung Cancer John Morris, MD Professor of Medicine Division of Hematology & Oncology Co-Director, Comprehensive Lung Cancer Center Associate Director of Translational Research and Director, Experimental Therapeutics University of Cincinnati Cancer Institute University of Cincinnati College of Medicine

Ovarian and Cervical Cancer Thomas Herzog, MD Professor of Obstetrics and Gynecology Deputy Director, University of Cincinnati Cancer Institute University of Cincinnati College of Medicine

Gastroenterological Malignancies Olugbenga Olowokure, MD Associate Professor of Medicine Division of Hematology & Oncology Director, Inpatient Services, University of Cincinnati Medical Center University of Cincinnati College of Medicine

Head and Neck Cancer Nooshin Hashemi, MD Assistant Professor of Medicine Division of Hematology & Oncology University of Cincinnati College of Medicine

Prostate Cancer Douglas Hawley, MD Associate Professor of Medicine Division of Hematology & Oncology University of Cincinnati College of Medicine

Lymphomas Tahir Latif, MD Associate Professor of Medicine Dirctor, Division of Hematology Oncology University of Cincinnati College of Medicine

Effects, Therapy, Survivorship Rekha Chaudhary, MD Adjunct Associate Professor of Medicine Division of Hematology & Oncology University of Cincinnati College of Medicine

Hematology Moderator: Tahir Latif, MD Associate Professor of Medicine Director, Division of Hematology Oncology Uniersity of Cincinnati College of Medicine

Myeloid Neoplasm and Hematopoietic Stem Cell Disorders Zartash Gul, MD Associate Professor of Medicine Division of Hematology & Oncology University of Cincinnati College of Medicine

Erythrocyte Disorders

Stephen Medlin, MD Associate Professor of Medicine Interim Chief, Hematological Malignancies and Bone Marrow Transplantation Division of Hematology & Oncology University of Cincinnati College of Medicine

Platelet, Bleeding, and Thrombotic Disorders Saulius Girnius, MD Assistant Professor of Medicine Division of Hematology & Oncology University of Cincinnati College of Medicine

Transfusion Mahmoud Charif, MD Associate Professor of Medicine Division of Hematology & Oncology University of Cincinnati College of Medicine

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Hematologic Issues in Pregnancy Tahir Latif, MD Associate Professor of Medicine Director, Division of Hematology Oncology University of Cincinnati College of Medicine

Palliative Care Moderator: Tahir Latif, MD Associate Professor of Medicine Director, Division of Hematology Oncology University of Cincinnati College of Medicine

Pain and Dyspnea

Anumeha Gupta, MD Assistant Professor of Medicine Division of Hematology Oncology University of Cincinnati College of Medicine

Depression and Anorexia

Elizabeth Rabkin, MD Associate Professor of Medicine Division of General Internal Medicine University of Cincinnati College of Medicine

Friday April 21, 2017

Endocrinology Moderator: Colin Carracher, MD Assistant Professor of Medicine Division of Endocrinology, Diabetes and Metabolism University of Cincinnati College of Medicine

Diabetes Mellitus Silvana Obici, MD Associate Professor of Medicine Division of Endocrinology, Diabetes and Metabolism University of Cincinnati College of Medicine

Robert Cohen, MD Professor of Medicine Division of Endocrinology, Diabetes and Metabolism University of Cincinnati College of Medicine

Thyroid Disorders Nadia Yaqub, MD Adjunct Associate Professor of Medicine Division of Endocrinology, Diabetes and Metabolism University of Cincinnati College of Medicine

Hypogonadism Colin Carracher, MD Assistant Professor of Medicine Division of Endocrinology, Diabetes and Metabolism University of Cincinnati College of Medicine

Pituitary Disorders Ruchi Bhabhra, MD Adjunct Assistant Professor of Medicine Division of Endocrinology, Diabetes and Metabolism University of Cincinnati College of Medicine

Adrenal Disorders Sona Sharma, MD Associate Professor of Medicine Division of Endocrinology, Diabetes and Metabolism University of Cincinnati College of Medicine

Calcium/Bone/Parathyroid Dima Diab, MD Associate Professor of Medicine Division of Endocrinology, Diabetes and Metabolism University of Cincinnati College of Medicine

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Saturday April 22, 2017

Nephrology

Moderator: Ganesh Yadlapalli, MD Professor of Medicine Division of Nephrology and Hypertension University of Cincinnati College of Medicine

Chronic Kidney Disease Kotagel Kant, MD Professor of Medicine Division of Nephrology and Hypertension University of Cincinnati College of Medicine

Acute Kidney Disease Charuhas Thakar, MD Professor of Medicine Director, Division of Nephrology and Hypertension University of Cincinnati College of Medicine

Primary and Secondary Hypertension Suresh Kamath, MD Professor of Medicine Division of Nephrology and Hypertension University of Cincinnati College of Medicine

Metabolic Acidosis and Alkalosis Manoocher Soleimani, MD Professor of Medicine Division of Nephrology and Hypertension Associate Chair for Research, Department of Medicine University of Cincinnati College of Medicine

Hyponatremia and Hypernatremia Satwant Singh, MD Professor of Medicine Director, Nephrology and Hypertension Fellowship Division of Nephrology and Hypertension University of Cincinnati College of Medicine

Hypokalemia and Hyperkalemia Ganesh Yadlapalli, MD Professor of Medicine Division of Nephrology and Hypertension University of Cincinnati College of Medicine

Geriatrics Moderator: Anna Goroncy, MD Assistant Professor of Clinical Medicine Department of Family and Community Medicine University of Cincinnati College of Medicine

Geriatric Assessment and Memory Issues Anna Goroncy, MD Assistant Professor of Clinical Medicine Department of Family and Community Medicine University of Cincinnati College of Medicine

Common Medical Problems Anna Goroncy, MD Assistant Professor of Clinical Medicine Department of Family and Community Medicine University of Cincinnati College of Medicine

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Friday April 28, 2017

Infectious Disease Moderator: George Smulian MD Professor of Medicine Director, Division of Infectious Diseases University of Cincinnati College of Medicine

Antibiotics Allison Kelly, MD Associate Professor of Medicine Division of Infectious Disease University of Cincinnati College of Medicine

Bloodstream Infections and Endocarditis

George Smulian MD Professor of Medicine Director, Division of Infectious Diseases University of Cincinnati College of Medicine

Central Nervous System Infections

Stephen Kralovic, MD, MPH Professor of Clinical Medicine Division of Infectious Diseases University of Cincinnati College of Medicine

HIV and Sexually Transmitted Infections

Jennifer Forrester, MD Assistant Professor of Clinical Medicine Division of Infectious Diseases University of Cincinnati College of Medicine

Pneumonia and Mycobacterial Infections

Lisa Haglund, MD Associate Professor of Clinical Medicine Division of Infectious Diseases University of Cincinnati College of Medicine

Skin Infections and Joint Infections Keith Luckett, MD Assistant Professor of Clinical Medicine Division of Infectious Diseases University of Cincinnati College of Medicine

Dermatology Moderator: Brian Adams, MD, MPH Professor and Drs. Mutasim, Gloster, Jr. & Claassen Endowed Chair of Dermatology University of Cincinnati College of Medicine Director of Sports Dermatology Chief of Dermatology, Cincinnati VA Medical Center

Dermatology Review for Internal Medicine Physicians

Anna Rogers, MD Assistant Professor of Dermatology University of Cincinnati College of Medicine

Brian Adams, MD, MPH Professor and Drs. Mutasim, Gloster, Jr. & Claassen Endowed Chair of Dermatology University of Cincinnati College of Medicine Director of Sports Dermatology Chief of Dermatology, Cincinnati VA Medical Center

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Saturday April 29, 2017

Cardiology Moderator: Alexandru Costea, MD Professor of Clinical Medicine Division of Cardiovascular Health and Disease Director, Center for Electrophysiology, Rhythm Disorders and Electro-Mechanical Interventions, UC Heart, Lung and Vascular Institute University of Cincinnati College of Medicine

Epidemiology and Risk Factors Hanan Kerr, MD Associate Professor of Clinical Medicine Division of Cardiovascular Health and Disease University of Cincinnati College of Medicine

Coronary Artery Disease Charles Hattemer, MD Professor of Clinical Medicine Associate Chief of Clinical Affairs Division of Cardiovascular Health and Disease University of Cincinnati College of Medicine Diagnosis Evaluation/Inpatient Management of Heart Failure Stephanie Dunlap, DO Associate Professor of Clinical Medicine Division of Cardiovascular Health and Disease Director, Heart Failure/Transplantation Fellowship Program University of Cincinnati College of Medicine Systolic Heart Failure: Medical and Device Therapy

Hareeprasad Vongooru, MD Assistant Professor of Clinical Medicine Division of Cardiovascular Health and Disease University of Cincinnati College of Medicine

Myocardial Disease Saad Ahmad, MD Assistant Professor of Clinical Medicine Division of Cardiovascular Health and Disease University of Cincinnati College of Medicine

Pericardial Disease Robert O’Donnell MD Associate Professor of Clinical Medicine Division of Cardiovascular Health and Disease Medical Director, Cardiovascular Ambulatory Services University of Cincinnati College of Medicine

Arrhythmias: Atrial Fibrillation, Ventricular Tachycardia, and Supraventricular Tachycardia Mehran Attari, MD Professor of Clinical Medicine Division of Cardiovascular Health and Disease Director, Clinical Cardiac Electrophysiology Fellowship Program University of Cincinnati College of Medicine

Aortic Stenosis and Regurgitation Jack Rubinstein, MD Associate Professor of Medicine Division of Cardiovascular Health and Disease University of Cincinnati College of Medicine

Mitral Stenosis and Regurgitation David Harris, MD Professor of Clinical Medicine Division of Cardiovascular Health and Disease Associate Director, Cardiovascular Disease Fellowship Program University of Cincinnati College of Medicine

Adult Congenital Heart Disease Christopher Learn, MD Assistant Professor of Pediatrics Director, Adult Congenital Heart Disease Fellowship Program Cincinnati Children’s Hospital Medical Center

Acute Aortic Syndromes and Aortic Aneurysms

Mohamed Effat, MD Professor of Clinical Medicine Division of Cardiovascular Health and Disease Director, Interventional Cardiology Fellowship Program University of Cincinnati College of Medicine

Peripheral Artery Disease Donald Lynch, MD Assistant Professor of Clinical Medicine Division of Cardiovascular Health and Disease University of Cincinnati College of Medicine

Pregnancy and Cardiovascular Disease Umara Raza, MD Assistant Professor of Clinical Medicine Division of Cardiovascular Health and Disease University of Cincinnati College of Medicine

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Friday May 5, 2017

General Medicine Update Moderator: Mark Eckman, MD Posey Professor of Medicine Director, Division of General Internal Medicine University of Cincinnati College of Medicine

Obesity Angela Fitch, MD Associate Professor of Medicine Division of Division of General Internal Medicine Director, Medical Weight Management University of Cincinnati College of Medicine

Pre-Operative Medicine Justin Held, MD Assistant Professor of Clinical Medicine Division of General Internal Medicine University of Cincinnati College of Medicine

Delirium and Dementia Elise Henning, MD, MEd Geriatric Medicine Fellow Department of Family and Community Medicine University of Cincinnati College of Medicine

Pain Management Michael Binder, MD Assistant Professor of Clinical Medicine Division of General Internal Medicine University of Cincinnati College of Medicine

Headache

Vince Martin, MD Professor of Medicine Division of General Internal Medicine University of Cincinnati College of Medicine

Saturday May 6, 2017 Self-Evaluation Process (SEP) Modules Moderator: Gregory Rouan, MD Gordon and Helen Hughes Taylor Professor of Medicine Chair of Internal Medicine University of Cincinnati College of Medicine

Internal Medicine Hospital Medicine Cardiology Hematology

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ACTIVE: Any physician who has a current MD/DO license to practice issued by the State Medical Board of Ohio.

Previous Member -- Physicians who held previous Active membership in the Academy. [$399.00]

New/First Year Member -- Physicians with no prior Academy Active membership history. [$199.00] Part-Time Member -- Physicians with a current MD/DO license to practice is issued by the State Medical Board of Ohio and practicing less than twenty (20) hours per week. [$199.00] NON-RESIDENT: Any physician holding a current license to practice medicine, who conducts the major portion of his or her practice outside of Hamilton County, Ohio. [$195.00]

POST-GRADUATE TRAINEE: Any physician who has a current certificate or license issued by the the State Medical Boad of Ohio and is enrolled in an approved internship, residency, or fellowship program. [First year, complimentary; subsequent years, $30.00]

ASSOCIATE: Allied health practitioners holding a current license to practice in Ohio. [$195.00]

AFFILIATE: Individuals interested in the work of the Academy who are not eligible for other Academy membership. [$75.00]

HEALTH CARE ADMINISTRATOR: Any individual holding an executive/management position in a hospital or other health care facility. [$150.00]

STUDENT: Any person who is enrolled in an approved college of medicine pursuing the degree of MD/DO. [Complimentary]

ACADEMY OF MEDICINE OF CINCINNATI7265 Kenwood Road Suit 315 Cincinnati, OH 45236-4411

513-421-7010 Fax 513-721-4378 www.academyofmedicine.org

PAYMENT OPTION Send Invoice Check enclosed(make checks payable to the Academyof Medicine of Cincinnati) Charge to VISA MasterCard American Express Discover

Account #__________________________________ Expiration Date_____________________ Name on credit card______________________________ Amount charged $____________

Cardholder Address______________________________________________________________

Cardholder’s Signature______________________________ Phone______________________

Payment arrangements are available and can be made by calling the Membership Department at 513-421-7010

If paying by check, return the completed application and check by mail to Academy of Medicine Membership Department, 7265 Kenwood Road, Suite 315,

Cincinnati, OH 45236-4411.

If paying by credit card, you may return the application by mail or fax to 513-721-4378.

MEMBERSHIP DUES INFORMATION/APPLICATIONAcademy of Medicine of Cincinnati Membership Categories

Please check appropriate membership category, select a payment option, and complete application on the next two pages.

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MEMBERSHIP APPLICATION(Please print. Complete items applicable to your membership category).

________________________________________________________________________________________________________________________First Name Middle Last Name MD/DO/Other

__________________________ Male Female __________________________________________________________________________Date of Birth Medical School Graduation Date (actual or expected)

______________________________________________________________________________________________________________________________________________________Home Address City State Zip Code

________________________________________________________________________________________________________________________Home/Cell Phone Preferred Email Address

Active/Non-Resident/Associate/Health Care Administrator Members

________________________________________________________________________________________ Independent EmployedPractice/Group Name Web Address

________________________________________________________________________________________________________________________Primary Office Address City State Zip Code

________________________________________________________________________________________________________________________Primary Office Telephone Office Fax

________________________________________________________________________________________________________________________Primary Specialty Board Certification Secondary Specialty Board Certification

Preferred Mailing/Billing Location: Office Home

Post-graduate Trainee Members

I am a Resident Fellow. I anticipate entering practice in the year_______________.

_______________________________________________________________________________________________________________________Training Facility Dates Specialty

All Membership CategoriesIf accepted as a member, I agree to abide by the Academy of Medicine of Cincinnati Articles of Incorporation and Code of Regulations. I understand and agree that by providing my address, email(s), telephone number(s), and fax number(s), I consent to recieve communications sent by or on behalf of the Academy of Medicine of Cincinnati via regular mail, email, telephone, or fax. By signing, I agree to the terms and conditions listed here.

Signature:__________________________________________________________________ Date:_______________________________________

Please Complete All Parts of Application. Questions, Call 513-421-7010.

Internal Use Only-Academy of Medicine of Cincinnati Approval

Name _________________________________ Title________________________ Please Print

Signature_____________________________________ Date __________________________