MOC Individual Project

MOC Enrollment Fee

Please provide the information below. Once the project enrollment is completed, you will be contacted regarding next steps. A processing fee of $50 per physician per project is required for individual QI projects.

Project Information

Enrollment Date*

Title/Topic*

Physician Participant

Name*

Organization*

Title*

Phone Number*

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Email*

Project Participation*

Processing Fee ($50.00)

Billing Information

Email*

Name*

Payment Method

Credit Card
Check

Credit Card*

Visa
Mastercard
American Express
Discover

Address*

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