Clinician Membership – Free CME (Select States)

Application Process

#### Application Submission
Submission Method: Online form at neuroimmune.org/clinicians/select-states-clinician-opportunities/

Status: Form active and accepting applications

#### Required Information

1. Personal Information:
- First name
- Last name
- Professional email address (required for verification)

2. Practice Information:
- Practice name
- Practice mailing address (street address, optional line 2, city, state, ZIP)
- Practice email

3. Professional Credentials:
- Professional type (select one):
- MD/DO
- NP/PA
- Medical Student (proof required)
- PhD
- Therapist
- Educator
- NPI number

4. Patient Population:
- Select: Pediatric, Adult, or Both

5. Practice Type:
- Select one or more:
- Private practice
- Clinic
- Hospital
- Educational (school or related)
- Therapy Practice
- Research

6. Insurance/Payer Information:
- Checkboxes (select applicable):
- "My practice is in-network with several insurance providers"
- "My practice takes Medicaid"
- "My practice does not take insurance"
- "Not applicable (research or educational settings)"

7. Prior Event Attendance:
- Question: "Have you attended any prior Neuroimmune Foundation events?"
- If yes, list events attended
- Note: Must not have attended prior events to be eligible

#### Verification Process

#### Additional Resources Available Upon Approval