FCUCM Application
Upon receipt of your application, an invoice for the application fee will be issued. Once payment is received, your application will be forwarded to the CUCM Review Committee for evaluation.
CUCM Fellowship Application (choose application type below)
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Physician
Advanced Practice Clinicians
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Physician
Applicant Information
Name
Date of Birth
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Medical Credentials
Email address
example@example.com
Organization
Medical License number
Medical License state
Medical School Graduation Year
NPI #
To be considered for CUCM Fellowship applicants must have the following:
Graduation resulting in an MD or DO degree from an accredited medical school recognized in the US, Canada, or equivalent
Unrestricted, active license to practice medicine, in good standing
Completion of a residency in a specialty relevant to the practice of Urgent Care.
If the specialties are not in the field of Family Medicine, Internal Medicine, Pediatrics, Emergency Medicine or Occupational /Environmental Medicine, please submit an explanation of relevancy.
Minimum 2000 hours of urgent care experience within the most recent 2 years (confirmed with a letter from employer, pay stub, notarized affidavit, or other documentation)
Two letters of recommendation from a physician peer or physician Board Member of UCA or CUCM
Active membership in CUCM for no less than 1 year
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Active and unrestricted license in the US or Canada in good standing, please select your state
Working in urgent care for minimum of 2000 hours in last 2 years (confirmed with a letter from employer, pay stub, notarized affidavit, or other documentation) Upload documentation here or email to Carly Gregan | cgregan@ucaoa.org
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Two letters of recommendation from a physician peer or physician board member of UCA or CUCM. Upload letters here or have emailed to Carly Gregan| cgregan@ucaoa.org
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Completion of residency (indicate specialty below)
Completion of residency (indicate specialty below)
Family Medicine
Internal Medicine
Emergency Medicine
Pediatrics
Other
Residency completion documentation
Upload here or email to Carly Gregan | cgregan@urgentcareassociation.org
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Advanced Practice Clinicians
To be considered for CUCM Fellowship applicants must have the following:
Graduation from an accredited US nurse practitioner or physician assistant program
Unrestricted, active license to practice medicine, in good standing
Minimum 5000 hours of urgent care experience within previous 5 years (confirmed with a letter from employer, pay stub, notarized affidavit, or other documentation)
Two letters of recommendation from a physician peer or Board Member of UCA or CUCM
Active membership in CUCM for no less than 1 year
Applicant Information
Name
Date of Birth
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Month
-
Day
Year
Date
Medical Credentials
Email address
example@example.com
Organization
NP/PA program name - graduated from
Graduation Year
APP License #
NPI #
Active and unrestricted license in the US or Canada in good standing, choose state
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Working in urgent care for minimum of 5000 hours in last 5 years (confirmed with a letter from employer, pay stub, notarized affidavit, or other documentation) Upload documentation here or email to Carly Gregan |cgregan@urgentcareassociation.org
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Two letters of recommendation from a physician peer or physician board member of UCA or CUCM. Upload letters here or have emailed to Carly Gregan |cgregan@urgentcareassociation.org
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Active CUCM membership for at least one year (If you are unsure - email membership@ucaoa.org for confirmation)
Yes, I have been a CUCM member for at least one year
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Three items of the following activities:
Completion of advanced education including but not limited to a second specialty certification, master's degree, Ph.D., law degree, etc.
Activities within UCA/CUCM: board member, committee chair or member, conference speaker, clinical advisor, task force member, etc
Leadership in Urgent Care: Medical Director, peer reviewer, quality improvement, other administrative activities, military service in a medical capacity
Publication(s) in subject relevant to urgent care: journal article, book chapter, online teaching program, webinar, etc.
Teaching responsibility including peers, nurse practitioners, physician assistants, medical students, university appointments, etc.
Research in a subject relevant to the practice of urgent care medicine
Continuing medical education: 25 credits within the last 2 years in subjects relevant to urgent care (Certificates may be requested)
Upload your CV here: (be sure the activities chosen are included for verification)
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Why are you applying to be a Fellow of the College of Urgent Care Medicine? What attracted you to the program?
Signature
Documentation of the above including certificates, letters, and attestations to the satisfaction of the Fellowship Committee is the sole responsibility of the candidate for Fellowship and may be approved or disallowed at the discretion of the Fellowship Committee Chair or President/VP of the Board of Directors of the College of Urgent Care Medicine. A committee vote will be held at the request of the applicant if the applicant disagrees with rejection. Persons elected to Fellowship will be encouraged to use the initials "FCUCM" in conjunction with professional activities until which time they are no longer a member in good standing within the College. Fees, qualifications, determination, and termination of candidates/Fellows are at the sole discretion of the Board of Directors of the College of Urgent Care Medicine
I attest that, to the best of my knowledge and belief, all information in the above referenced data reported is accurate and complete.
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