Multi-Specialty Portfolio Program – Physician Participation and Reflection Attestation

  • This attestation must be completed by each certified physician seeking MOC Part IV credit from one of more of the participating ABMS Member Boards. The physician must have participated in an approved QI Effort and have satisfied all of the participation requirements of the QI Effort. This attestation must also be "cosigned" (an electronic form is provided for this purpose) by the project leader, as determined by the Portfolio Sponsor. The completed and signed attestation will be retained by the Portfolio Sponsor who will notify the Portfolio Program of the physician's completion of the QI Effort. Please note that participating ABMS Member Board MOC fees, if applicable, must be current and are the responsibility of each member physician, in order for the physician to receive MOC Part IV credit.

  • Physician Participant Seeking MOC Part IV Credit

  • Certifying Board 
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Details of the QI Effort

  • Reflection

  • Attestation Statement

  • Drop files here or
  • Date Format: MM slash DD slash YYYY
  • If the Submit button below is dimmed, you have not fully completed the application. Please review the form for any required fields (with a red asterisk) that you may have missed.