Fillable APNA 19th Annual Clinical Psychopharmacology Institute 10% Risk

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APNA 19th Annual Clinical Psychopharmacology Institute 10% Risk

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EMAIL to: emc-hatboro@aon.com
APNA 19th Annual Clinical
Psychopharmacology Institute
10% Risk Management Discount
Conference CE Form
*Coverage is available to eligible residents of the United States of America and Puerto Rico.
*Discount available for individual policies only and does NOT apply to practice or business policies (i.e. LLC, PC, INC or pr actices
with multiple employees).
*(Discount applied at each renewal for three years)
Instructions:
(1) You must secure a total of 6.0 Contact Hours (0.6 CEUs) or more by attending a combination of approved
Learning Institutes (LIs), 90 minute and/or 60 minute education sessions from your Association’s
Conference Guide or Virtual CE Opportunities. 30-Minute Sessions are NOT approved.
(2) Include your name, address and policy number (if applicable) in the space provided below.
(3) Sign the form. Unsigned forms will not be processed.
(4) Make a copy of this form for your records.
(5) A) If you are a current NSO customer with an individual professional liability insurance policy then you may
email a copy of this form to emc-hatboro@aon.com.
B) If you are not currently an NSO customer, please contact www.NSO.com to obtain an application for
coverage. Return the completed application and a copy of this form to NSO at:
Nurses Service Organization
1100 Virginia Drive, Suite 250
Fort Washington, PA 19034
(Print clearly)
Association Partner:
Name:
Address:
City/State/Zip:
Policy Number:
Please list the Approved Session you attended below:
Note each daytime LI = 6.0 CE, evening LI -= 3.0 CE, 90 Minute Session = 1.5 CE, and each 60 Minute Session = 1.0 CE
Date
Time
Program #
Title
CE Amount
Total CE Amount (You must secure a total of 6.0 CEs or more)
I certify that the information I have reported on this form is complete and accurate.
Signature___________________________________________________ Date: ____________________
Ineligible Sessions:
June 10th - Keynote: Mental Health Impacts of COVID-19
June 11th - Keynote: Alcohol Use Disorder: Hyperkatifeia, Deaths of Despair and COVID-19
June 12th - Keynote: Early Treatment, Outcomes, and Course
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APNA 19th Annual Clinical Psychopharmacology Institute 10% Risk

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Completed 20 June 2021

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