Good Samaritan Hospital CME Activity Request & Conflict of Interest Disclosure
To Be Filled Out By The Planner Before the Proposed CME Activity


You must answer all required questions marked with an asterisk(*). Otherwise, you will not be able to submit this form. If you close the form before all answers are complete, the information will not be saved.

(1) We request that the completed form be received by the Medical Staff Office 3 months prior to the proposed CME activity.

(2) The CME Committee will review your submission within a 20 day time frame.

(3) The CME Coordinator will then notify you when the activity is approved/not approved along with any relevant corrections and/or revisions.

Please Note: The CME Committee grants one (1) AMA PRA Category 1 Credit™ per one (1) hour.

If you have any difficulties filling out this form please feel free to contact Sandra Vasti, CME Coordinator at or (845) 368-5971.

Thank you for your time!

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