Form

Request Your LGH CME Credit

This form may be used for making one-time or recurring requests at regular intervals.
Your Name:*
I am a(n):*

Physician Physician's Assistant Nurse Practitioner Allied Health Professional
I am:*

Currently affiliated with LGH No longer affiliated with LGH
Have you attended CME programs at the LGH Saints campus during the timeframe you are currently requesting?*

yes no

Your email address:*
For verification purposes, the last five digits of your LGH library card are required:*
Your Campus (if not applicable, write N/A in this space):*
Your Department (if not applicable write N/A in this space):*
This is:*

A new request, or a one-time request A request to change details about a previously submitted recurring request

Making a New Request

For your convenience, if you request a regularly scheduled report, we will automatically run your report at the frequency you've requested, so there should be no reason to re-submit this form unless your information changes or in the event you do not receive your requested reports. In the event that a practitioner does not have any credit during the specified time period, no report will be sent. Questions? Please contact us at x76247.
This is:*

A one-time request A request for a regularly scheduled report (monthly, quarterly, annually)
Date range being requested (MM/DD/YY-MM/DD/YY):
For recurring requests, please specify the frequency you would prefer to receive credit reports:*

Monthly Quarterly Annually

Revising a Previously Submitted Request
I want to:*

Change the frequency of my previous request Cancel the request, such as when a practitioner leaves the hospital or practice
The previous report frequency I requested was:

Monthly Quarterly Annually
The new report frequency I am requesting is:

Monthly Quarterly Annually

We're sorry...

We are unable to verify your identity. For reasons of confidentiality, please contact us at x76247 for further information about requesting your LGH CME credit.
Should be Empty:

Request Your LGH CME Credit