MOC Registration Form

Registration Form

Please enter the following information as it appears on your IAC accreditation documentation:
Name of Accredited Facility (as displayed on the IAC Certificate of Accreditation):*
Accreditation Number (Application number or Account ID):*
Physicians must register individually. Only physicians listed as Medical Director or medical staff in an accredited facility are eligible to participate in this project. The Medical Director or medical staff member must be listed on the Manage Staff tab of the Online Accreditation account in order to participate in the MOC Activity.
Full Name:*

PrefixFirst NameLast NameSuffix / Designation
Phone Number:*

Area CodePhone Number
E-mail:*
Credit Type (Select one or more credit types below. You must include your Diplomate ID #; for ABIM credit, you must also include your date of birth (DOB)):*

ABIMABPABR
ABIM Diplomate Information*
ABP Diplomate Information*
ABR Diplomate Information*
Applicable Modalities - Select the modalities applicable for the MOC program for this physician. Note: Physicians must be accredited in the selected modalities to proceed with the MOC program (select all that apply):*

Cardiac ElectrophysiologyCardiovascular CatheterizationCTDental CTEchocardiography - AdultEchocardiography - PediatricMRINuclear/PETVascular Testing
Once all of the required fields above have been completed, click the [PROCEED TO QUIZ] button below to complete a brief 5 question quiz specific to the IAC QI Maintenance of Certification Activity presentation. The registration cannot be submitted until the quiz is complete.