IAFP Diabetes PI Registration form

Diabetes Self-Management Education Performance Improvement

REGISTRATION

Please complete this form to indicate your interest in completing the IAFP Diabetes PI project.

This project is free for physicians to complete

Funding for this project was made possible by a grant from the American Board of Family Medicine.

The Illinois Academy of Family Physicians (IAFP) oversees and manages the Diabetes Self-Management Education Performance Improvement project. This initiative aligns with the American Board of Family Medicine (ABFM) Performance Improvement standards and fulfills Meaningful Participation requirements.

Questions? Please contact Kate Valentine at kvalentine@iafp.com
Name*

First NameLast Name
Credentials *
ABFM Board ID *
ABFM Board IDs are 6 digits and being with a 1 or zero
AAFP member number
To claim and submit AAFP Prescribed credits
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.
Start Date of Participation*

MonthDayYear
Date
Anticipated End Date of Participation*

MonthDayYear
Date
AIM - What are you trying to accomplish?*
Questions or Comments for IAFP staff
Should be Empty: