I n v i t a t i o n t o A A P S D i p l o m a t e s , M e m b e r s ,

a n d C o l l e a g u e sJoin your fellow Diplomates, Members,

and other professionals to learn

“What Every Physician Should Know about Disasters.” You can register for education sessions

only and earn CMEs or register for business

sessions only and attend your Academies of

Medicine, ABPS Boards of Certification,

and Standing Committees.

Take advantage of our meeting location at the

Ritz-Carlton Hotel, Tysons Corner, VA, to enjoy

the many historical and educational attractions

in the Washington, D.C., area – a perfect

vacation for families.

We H o p e To S e e Yo u T h e r e !

O v e r a l l M e e t i n g O b j e c t i v e s• Provide physician specialists with up-to-date information

regarding what to do when disasters strike.

• Provide a forum in which to discuss developing and emerging issues in your specialty.

• Plan and conduct the business of the AAPS, its affiliated Academies of Medicine, and its Boards of Certification.

• Encourage collegial relations to enable members to pursue their professional goals to participate in the Association’s activities.

I n t e n d e d A u d i e n c eABPS Diplomates and AAPS Members in:

A c c r e d i t a t i o n S t a t e m e n tThe American Association of Physician Specialists, Inc. (AAPS), is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Anesthesiology

Dermatology

Diagnostic Radiology

Disaster Medicine

Emergency Medicine

Family Medicine Obstetrics

Family Practice

Geriatric Medicine

Hospital Medicine

Internal Medicine

Obstetrics & Gynecology

Ophthalmology

Orthopedic Surgery

Plastic & Reconstructive Surgery

Psychiatry

Radiology & Radiation Oncology

Surgery

Urgent Care

C M E C r e d i t S t a t e m e n tAnnual Meeting – Scientific Presentations, June 21 and 22: The AAPS designates this educational activity for a maximum of 16 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Examination Development Workshop I, June 23 – The AAPS designates this educational activity for a maximum of 6.5 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Examination Development Workshop II, June 25 – The AAPS designates this educational activity for a maximum of 6.5 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

E a r n C M E s b y p a r t i c i p a t i n g i n . . .

• Up to16.0 CMEs Scientific Presentation sessions

• Up to 7.5 CMEs Medical Ethics course

• Up to 13 CMEs Examination Development Workshop

C M E C o m m i t t e eKenneth M. Flowe, M.D., FAAEP, MBA, Co-Chair

Stephen A. Montes, D.O., FAASOS, Co-Chair

Muhammad A. Ahmed, M.D.

Thomas A. Castillo, D.O., MBA, FAASS

Jack V. Greiner, D.O., PhD, FAASS

Gustavo G. Leon, M.D.

Jerry R. Majers, D.O., FAAIM, FAAGM

Herbert Pardell, D.O., FAAIM

Luis M. Velasco, M.D.

M e d i c a l E t h i c sThis course provides a solid conceptual grounding in medical ethics, while focusing on practical issues and tested approaches for resolving such issues. This course satisfies a professional development requirement for fulfilling, in part, Board recertification of the American Board of Physician Specialties of the AAPS.

Medical ethics course

Practical Issues and Approaches 7.5 CMEs $450.00 - Separate registration required

course option #1 - one-day course

Monday, June 20, from 8:00 a.m. to 5:00 p.m.

course option #2 - one-day course

Thursday, June 23, from 8:00 a.m. to 5:00 p.m.

C o u r s e O b j e c t i v e sUpon completion of this program participants should be able to:

1. Understand the theoretical and historical foundations of medical ethics;

2. Engage in allocation of resources decisions;

3. Apply ethical decision-making tools to actual circumstances;

4. Understand the appropriate roles of medical ethics/bioethics committees and be able to constructively contribute to these committees;

5. Recognize the stakeholders in medical ethics decisions and weigh stakeholder ethical perspectives; and

6. Guide public discussion of medical ethics issues and explain the perspectives of medical professionals on such issues.

Accreditation Statement: The American Association of Phy-sician Specialists, Inc. (AAPS), is accredited by the Accredita-tion Council for Continuing Medical Education to provide con-tinuing medical education for physicians.

CME Credit Statement: The American Association of Physi-cian Specialists, Inc., designates this educational activity for a maximum of 7.5 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Recertification Credit: This course fulfills ABPS recertifica-tion requirements for Medical Ethics. CME credit earned for attending this course may also be applied to the CME recerti-fication requirements.

According to AMA policy, physicians may not claim credit for attending the same activity more than once, unless there has been a substantial change in the materials that had been previously presented.

A A P S A u x i l i a r yJoin the AAPS Auxiliary at its Annual Meeting and Brunch on Thursday, June 23, at 10:00 a.m. Learn about its mission and goals, join in family-friendly activities, meet other spouses and family members. Auxiliary dues are $50 per year and may be paid with Certification Maintenance Fees, at the Annual Meeting, or at any other time during the year.

Be sure to check the Auxiliary schedule at the Registration Desk for the latest updates.

A A P S A u x i l i a r y S c h e d u l eWednesday, June 22

9:30 a.m. – 3:30 p.mWhite House Tour & d.C. sightseeing*Leave Ritz-Carlton Hotel at 9:30 a.m.

Transportation courtesy of aaPs auxiliaryyOu MusT ReGIsTeR – see Registration Form

*Based on sufficient registrations

THuRsday, June 23

10 a.m. – 12 noon annual auxiliary Meeting and Brunch

1 p.m. until donedecorate for Welcome Reception

Volunteers Welcome – JusT sHOW uP!

6 p.m. – 9 p.m. Welcome Reception - “Red, White & Blue”

all tickets courtesy of aaPs auxiliaryyOu MusT ReGIsTeR

FRIday, June 24

9:30 a.m. – 3:30 p.mTrip to Mount Vernon – Home of George Washington

admission and transportation courtesy of aaPs auxiliary

A Great Hotel in a Great Location – centrally located in the heart of Tysons Corner

• PreparetobepamperedatTheRitz-CarltonHotelTysonsCorner,McLean,VA.

• Easyaccesstotwomajorairports(WashingtonDullesInternationalandReaganWashingtonNational).

• NearbyMetrosystemconnectingNorthernVirginia,theDistrictofColumbia,andMaryland.

• Stepsawayfromtwoleadingshoppingcenters.

• Convenienttohistoricsights,museums,monuments,battlefields–allthattheWashingtonareahastooffer.

Select your schedule

• ChoosetheCMEPackageortheBusinessPackageortheSpecialDiscountPackage.

Great Pricing and Generous Deadlines

• RegisterforCMEsessionsonlyorBusinesssessionsonlyorboth.YounolongerneedtopayfortheentireweektoattendonlyCMEoronlyBusinesssessions.

• TakeadvantageofbestpricesduringEarlyRegistration–THISISYOURBESTBUY!!!

• EarlyRegistrationuntilMarch15,2011

• Still-Time-To-RegisteruntilMay28,2011

M a k e a C a p i t a l I n v e s t m e n t i n Y o u r F u t u r eA t t e n d t h e 2 0 1 1 A n n u a l M e e t i n g

m e e t i n g h i g h l i g h t s

Welcome Reception

• TheAAPSAuxiliarywillprovidecomplimentaryticketstotheWelcomeReception.

Two opportunities for Medical Ethics

• One-daycourseofferedonMonday,June20

• One-daycourseofferedonThursday,June23

CMEs for Recertification

• EarnCMEstofufillyourABPSRecertifcationRequirement

Board of Directors Meeting

• EveryoneisencouragedtoattendallorpartoftheBODmeetingonJune23.LearnvaluableinformationaboutAAPSpolicies,directions,andfuturedevelopments.LearnthelatestdecisionsbytheBoardofDirectorsastheyaremade.

Orientation Session

• Required forallnewlyelected/appointedmembersofAcademiesandBoards.ThisinformativesessiononSaturday,June25,from8:30a.m.to10:30a.m.willoutlineyourresponsibilitiesaswellastheproceduresoftheAssociation.

Flash drives

• Providedforyourconvenienceinsteadofbulkypapermaterials. NO HARD COPIES WILL BE PROVIDED.

M a k e a C a p i t a l I n v e s t m e n t i n Y o u r F u t u r eA t t e n d t h e 2 0 1 1 A n n u a l M e e t i n g

m e e t i n g h i g h l i g h t s

daily

7 a.m. – 5 p.m...........................................Registration.Desk

Monday, June 20

7 a.m. – 8 a.m. ............................Medical.Ethics.Breakfast

8 a.m. – 5 p.m. ............................... Medical.Ethics.Course

12:30 p.m. – 1 p.m. ..........................Medical.Ethics.Lunch

tuesday, June 21

7 a.m. – 8 a.m. ........... CME.Package.Breakfast.for.registrants

8 a.m. – 5 p.m. .................................. CME.Scientific.Sessions

12 noon – 1 p.m. .............CME.Package.Lunch.for.registrants

Wednesday, June 22

7 a.m. – 8 a.m. ........... CME.Package.Breakfast.for.registrants

8 a.m. – 5 p.m. .................................. CME.Scientific.Sessions

9:30 a.m. – 3:30 p.m. ......... .AAPS.Auxiliary.White.House.Tour

12 noon – 1 p.m. .............CME.Package.Lunch.for.registrants

thursday, June 23

7 a.m. – 8 a.m. ......Business.Package.Breakfast.for.registrants

7 a.m. – 8 a.m. ..............................Medical.Ethics.Breakfast

8 a.m. – 5 p.m. ................................. Medical.Ethics.Course

12:30 p.m. – 1 p.m. ............................Medical.Ethics.Lunch

8 a.m. – 12 noon ........................ Board.of.Directors.Meeting

8 a.m. – 3:30 p.m. ...................... All.Specialties.Credentialing. Open to diplomates Only

8 a.m. – 3:30 p.m. ...All.Specialties.Examination.Development Open to diplomates Only

10 a.m. – 12 noon ...................Auxiliary.Brunch.and.Meeting

12 noon – 1:30 p.m. ............................... Lunch.on.your.own

1 p.m. – ? ................ Auxiliary.Welcome.Reception.Decoration

1:30 p.m. – 2:45 p.m. .............Council.of.Academy.Presidents

1:30 p.m. – 3:30 p.m. ................ American.Board.of.Physician.Specialties.(ABPS).Meeting

3:30 p.m. – 5:30 p.m. .........Governmental.Affairs.Committee/.Strategic.Planning.Meeting

6 p.m. – 9 p.m. ....................................... Welcome.Reception “Red, White & Blue” all american Theme

S C H E D u l E O F E v E n T S

Friday, June 24

7 a.m. – 8:30 a.m. ....... Business.Package.Breakfast.for.registrants with International speaker

8:30 a.m. – 10 a.m. ............ Academies.of.Medicine.Meetings.(anesthesiology, dermatology, disaster Medicine, Family Practice,

Internal Medicine, Orthopedic surgery, and surgery)

8:30 a.m. – 12 noon. ............................. Emergency.Medicine.Credentialing.Committee

9:30 a.m. – 3:30 p.m.......AAPS.Auxiliary.Trip.to.Mount.Vernon

10:15 a.m. – 12 noon ..........Boards.of.Certification.Meetings(anesthesiology, dermatology, disaster Medicine, Family Practice,

Internal Medicine, Orthopedic surgery, and surgery)

12 noon – 1:30 p.m. ............................... Lunch.on.your.own

1:30 p.m. – 3 p.m. .............. Academies.of.Medicine.Meetings. (emergency Medicine, Radiology)

1:30 p.m. – 3:15 p.m. ...........Boards.of.Certification.Meetings(Hospital Medicine, urgent Care)

3:15 p.m. – 5 p.m. ................Boards.of.Certification.Meetings(emergency Medicine, Family Medicine Obstetrics, Radiology)

4 p.m. – 5:30 p.m. .........AAPS.Education.Foundation.Meeting

saturday, June 25

7 a.m. – 8:30 a.m. .......................Business.Package.Breakfast.with speaker

8:30 a.m. – 10 a.m. ........................CME.Committee.Meeting

8:30 a.m. – 10:30 a.m. .........Board.and.Academy.Orientation(Required for newly elected BOC and academy members)

8:30 a.m. – 3:30 p.m. .....All.Specialties.Examination.Development.Open to diplomates Only

10:15 a.m. – 11:45 a.m. ...................Membership.Committee.

10:30 a.m. – 11:30 a.m. ........................ Emergency.Medicinespecial Presentation on eM Workforce

10:30 a.m. – 12 noon. ...................... Public.Member.Meeting

12 noon – 1:15 p.m. ............................... Lunch.on.your.own

1:15 p.m. – 2:45 p.m. ..............AJCM.Editorial.Board.Meeting

1:15 p.m. – 3:15 p.m. ....................... Past.Presidents.Meeting

3:15 p.m. – 5:15 p.m. ..............................House.of.Delegates

6:15 p.m. – 7 p.m. ................................ President’s.Reception

7 p.m. – 10 p.m. ............................ President’s.Awards.Dinnerwith featured speaker

all meetings and events are open to all registered attendees unless noted otherwise on the schedule.

schedule is subject to change.

S p e a k e r sArthur L. Berman, D.O., FAAIM AcuteGastrointestinalBleedinginaDisaster

Graeme A. Browne, M.D. DamageControlResuscitation:TheCaseforEarlyUseofBloodProducts&HypertonicSalineinResuscitatingExsanguinatingTraumaVictims...

Arthur Cooper, M.D. HealthcareIncidentManagementSystem

Robert Cross, M.D., ABS, FACS ShelterinPlaceFamilyFirst

Mark DeSantis, D.O. RadiologicalScienceintheEnvironmentofRadiologicalTerrorism

Kenneth M. Flowe, M.D., FAAEP, MBA HowaSmallHospitalShouldPrepareforDisasters

Ashley L. Greiner, M.D., MPHJack V. Greiner, D.O., PhD OphthalmologicGuidelinesandtheDisasterResponse:TreatmentIntervention,MobileEyeClinics,andDisasterTeamEyeTraining

Surinder K. Kad, M.D., FAAIM, MPH, MBA BiologicalWarfare

ChemicalAgentsUsedinWarfare

David M. Lemonick, M.D., FAAEP EpidemicsafterNaturalDisasters

BombingsandBlastInjuries:APrimerforPhysicians

David G. C. McCann, M.D., FAASFP EarthquakeDisasterResponse:LessonsfromHaitiYouCanUseatHome

Karanita M. C. Ojomo, M.D.DisasterPreparednessforMassRadiationExposure

S. John Pappas, M.D. TopTwelveThingsPhysiciansNeedtoKnowWhenItComestoDisasters

Mark Pastin, PhD DisasterMedicine:IsEthicsBlackTagged?

Madonna Ringswald, D.O. SmokeInhalation

Albert Romanosky, M.D., PhD PreparingforDisaster:EmergencySupportFunction8:PublicHealthandMedicalPlanningforthe2009PresidentialInauguration

Geoffrey Simmons, M.D. DisasterPreparednessfortheMedicalProfessionalatHomeandattheWorkplace

Margaret C. Vives-Austin, M.D. TheEmergencyPhysicianandDisasters–TheTypesofInjuriesandWhatYouCanDotoAddressThemAll

Cyril H. Wecht, M.D., J.D. ForensicInvestigationinMassDisasters

A A P S S h o w c a s eThe Author Showcase has been expanded to include not only printed materials, but also your photography, art, or other works. We provide the means to display and you provide samples, order forms, and other information.

The AAPS Showcase is open to any registered participant and spouse/family member.

For more information call Esther Berg (813) 433-2277 Ext. 18 before April 15, 2011.

H o t e l I n f o r m a t i o nThe Ritz-Carlton, Tysons Corner

1700 Tysons BoulevardMcLean, Virgina 22102

Hotel Reservations: 800-241-3333Hotel Direct: 703-506-4300Hotel Fax: 703-506-4305

www.ritzcarlton.comGroup code: AAPAAPA

A C C O M M O D AT I O n S

H o t e l R e s e r v a t i o n sAAPS has a limited number of rooms available at the AAPS guaranteed room rate on a first come, first served basis. Hotel reservations must be made NO LATER THAN MAY 26, 2011. However, once the rooms in the AAPS block have been reserved, it is unlikely that you will be able to get the AAPS rate. Therefore, we strongly encourage you to make your reservations ASAP!

NOTE: If you make your reservation through another method, such as Travelocity, AAA, travel club, AARP, medical organization, etc., please let the AAPS Meeting Department know so that we can include these reservations toward our hotel room obligation. Due to contractual obligations, attendees eligible for hotel reimbursement will only be reimbursed for staying at the Ritz-Carlton, Tysons Corner.

Single or double occupancy $189 + tax per room per night (currently 9%). Children in same room with parents: Free.

Guaranteed room rate applies three days before and three days after meeting, based on availability at the time of the request.

Check-in after 3 p.m. • Check-out 12 noon.

Hotel cancellations by 12 noon on day of arrival.

Any problems making hotel reservations, call the AAPS Meetings Department.

T h e R i t z - C a r l t o nPrepare to be pampered! The Ritz-Carlton, Tysons Corner, located in the Washington, D.C., suburb of McLean, VA, in the Tysons Galleria, is just 20 minutes from downtown Washington, D.C. It is an area renowned for its shopping centers and an abundance of restaurants, offering tempting choices for every palate.

Easy access to our nation’s capital with its many attractions including museums, monuments, art galleries, and federal buildings is available by Metro. Hotel provides shuttle to metro station.

H o t e l A m e n i t i e sRitz-Carlton Day Spa Rejuvenate and refresh in style. Make your reservations for the Ritz-Carlton Day Spa, which offers facial and body treatments and salon services.

Fitness Center with cardiovascular and weight training equipment, a heated indoor pool and whirlpool, sauna and steam rooms, and personal training services. Open 24 hours.

Ritz-Carlton Afternoon Tea Experience Treat someone special – or yourself – to this enduring tradition honored in a luxurious setting while enjoying a lavish selection of sandwiches, flavorful scones, and a sumptuous display of sweets among other delicious decadences.

S h o p p i n gTysons Galleria, the location of the Ritz-Carlton Hotel, is Washington, D.C.’s premier upscale shopping center. Tysons Galleria offers some of the world’s most luxurious retailers, such as Burberry, Cartier, and Chanel, as well as a selection of boutiques. It includes more than 120 of the area’s most fashionable retailers, six upscale restaurants, plus many family-oriented eateries.

Tysons Corner Center A less-than-five-minute shuttle ride across the street from the hotel takes you to Tysons Corner Center with a 16-theater movie complex, numerous restaurants, and more than 300 stores including Macys, Lord & Taylor, Nordstrom, and Bloomingdales.

A t t r a c t i o n sNo matter what your interests – from archeology and art to battlefields, gardens, and historic sights to zoos and everything in between – there is an attraction to meet your needs close by in Northern Virginia, Washington, and Maryland. These include: Udvar-Hazy Air and Space Museum, Claude Moore Colonial Farm, Mount Vernon, historic battlefields, Wolf Trap National Park for the Performing Arts, the White House, Jefferson and Lincoln Memorials, Washington Monument, Smithsonian Institutions, FBI building, International Spy Museum, and many more monuments, art galleries, and museums.

u s e f u l To u r i s t W e b s i t e sFor information about Washington, DC, check out destinationdc.com

For information about Northern Virginia, check out fxva.com

C l i m a t e a n d C l o t h i n gSummer months typically vary from the high 80°s to the low 60°s with considerable humidity. We recommend that guests check the local listings to determine the weather conditions.

Casual clothing is recommended both in and out of the meeting rooms, with the exception of Saturday evening when a jacket and tie for men (black tie optional) and corresponding attire for women is requested. You may want to bring “layers” of clothing to accommodate all meeting room temperatures. As you know, meeting rooms can sometimes get chilly!

Tr a v e l I n f o r m a t i o nAirport: If traveling by air, make your reservations early to ensure the best airfare to either Washington Dulles International Airport, located 15 minutes/12 miles from the hotel, or Washington Reagan National Airport, located 20 minutes/15 miles from the hotel.

Airport Transportation: There is no hotel shuttle to/from the airports. Taxis are available for approximately $30-40 from either airport.

Hotel Parking: Hotel self-parking is available at $5 per day for AAPS registrants.

Hotel Shuttle Service: Complimentary hotel shuttle service is available on a first come, first served basis for trips within a three-mile radius of the hotel, including the West Falls Church Metro station and Tysons Corner Center, except during rush hour.

Metro Information: The closest Metro station is West Falls Church. You can take the complimentary hotel shuttle to the West Falls Church station – except during morning and afternoon rush hour. For additional Metro information, visit http://wmata.com or call 202-637-7000.

Special AAPS – Hertz Rental Rate: Make your reservation at www.hertz.com. Include PC# 148551

for meeting discount and CDP#1304113 for member discount.

MeMber categories

DIPLOMATE/EMERITUS/MEMBER

PRESEnTER

AAPS RETIRED MEMBER

nOn-MEMBER CME OnLy

registration packages

CME/EDUCATIOn Includes up to 16 CMEs for scientific presentations, conference materials, breakfast and lunch on Tuesday, June 21, and Wednesday, June 22. 2 days – See pricing on registration form.

BUSInESS/GOVERnAnCE Includes all meetings – Board of Directors, Academies of Medicine, Boards of Certification, House of Delegates, Committees, and any other scheduled business meetings, conference materials, and breakfast on Thursday, June 23, through Saturday, June 25. 3 days – See pricing on registration form.

SPECIAL DISCOUnT Includes CME/Education and Business/Governance Packages. 5 days – See pricing on registration form.

registration deadlines

BEST PRICES - EARLy REGISTRATIOn ByMarch15,2011

STILL-TIME-TO-REGISTER ByMay28,2011

LATE/On-SITE REGISTRATIOn AfterMay28,2011

R E g I S T R A T I O n

REGISTRATION FORM: AAPS 2011 HOuSE OF DElEGATES AND ANNuAl ScIENTIFIc MEETINGTO REGISTER by FAX: 813-830-6599 (cREDIT cARD ONly) • MAIl: AAPS, 5550 W. EXEcuTIvE DRIvE, SuITE 400, TAMPA, Fl 33609-1035

Name________________________________________________________________Email_Address:______________________________________________________

Address_ ____________________________________________________ City_____________________________ State_ _____________Zip_____________________

Cell_phone_ ________________________________ _Work_phone___________________________________ _Home_phone____________________________________

Special_dietary_or_accessibility_needs________________________________________________ For_(name_of_person)__________________________________________

WHITE HOuSE TOuR_____I_plan_to_attend_the_White_House_Tour_(If_more_than_one_person_is_attending,_please_attach_a_separate_form._YOU_MUST_PRE-REGISTER_to_attend.)Last_Name_ ________________________________ First_Name_ _________________________________ MI_________ Gender_ _______ DOB____________________

SSN___________________________ _Citizen____________ Country_ __________________ City_______________________________________State_______________

TO cOMPlETE THE REGISTRATION FORM bElOW, DO THE FOllOWING:

1. Review_Important_Registration_Information__

2._ Select_one_of_three_registration_packages_(CME,_Business,_Discount_Package)__

3._ Select_from_Additional_Options_(Medical_Ethics_Course,_Welcome_Reception,_President’s_Dinner)__

4._ Review_registration_table_on_right_and_circle_your_registration_choice.__Enter_fee_amount_in_subtotal_below._Early_Registration_deadline_March_15_for_best_prices.

_ Package_Subtotal_$________________MEDIcAl ETHIcS cOuRSE_Register_for_course_on_either_Monday_Or_Thursday.

_ Monday,_June_20_................................................................... $_450_per_person_x_________(#_attending)_=_ _$___________

_ Thursday,_June_23__................................................................. $_450_per_person_x_________(#_attending)_=_ _$___________

_ Medical_Ethics_Registration_Subtotal_$________________

NO ONE WIll bE ADMITTED TO ANy SESSIONS INcluDING MEAlS WITHOuT A vAlID bADGE

WElcOME REcEPTION (Complimentary,_but_you_must_register)_..................._ $_0_per_person_x______(number_of_tickets)_ _Welcome_Reception_Total__$________________

PRESIDENT’S DINNER_...................................................................................$__125_per_person_x______(number_of_tickets)_ _President’s_Dinner_Total__$________________

MEETING REGISTRATION PAyMENT _Check_enclosed_ _American_Express_ _MasterCard__ _Visa_ Total_to_be_charged:__$_ ________________

Cardholder’s_Name_________________________________________________Card_Number________________________________ Expiration_Date________________

Cardholder’s_Mailing_Address_ ____________________________________________________ Cardholder’s_Signature_ ______________________________________

PlEASE NOTE THERE ARE NO GuEST REGISTRATIONS AvAIlAblE NEW THIS yEAR - All PARTIcIPANTS MuST cOMPlETE - DISclOSuRE OF RElEvANT FINANcIAl RElATIONSHIPS

1._List_names_of_proprietary_entities_producing_health_care_goods_or_services,_consumed_by,_or_used_on,_patients,_ with_ the_ exemption_ of_ non-profit_ or_ government_ organizations_ and_ non-health_ care_ related_companies_with_which_you_or_your_spouse/partner_have,_or_have_had,_a_relevant_financial_relationship_within_ the_past_12_months._ _ For_ this_purpose_we_consider_ the_ relevant_financial_ relationships_of_ your_spouse_or_partner_that_you_are_aware_of_to_be_yours.

2._Describe_what_you_or_your_spouse/partner_received_(ex:_salary,_honorarium,_etc)._The_American_Association_of_Physician_Specialists,_Inc.,_does_NOT_want_to_know_how_much_you_received.

3._Describe_your_role.

1._Commercial_Interest

(Example:_Company_‘X’)

Nature_of_Relevant_Financial_Relationship_(Include_all_those_that_apply)

2._What_was_received_(Example:_Honorarium) 3._For_what_role?_(Example:_Speaker)

I_do_not_have_any_relevant_financial_relationships_with_any_commercial_interests.

Signature:__________________________________________________________________________________ Date:________________________Example Terminology

What was received:_Salary,_royalty,_intellectual_property_rights,_consulting_fee,_honoraria,_ownership_interest_(e.g.,_stocks,_stock_options_or_other_ownership_interest,_excluding_diversified_mutual_funds),_or_other_financial_benefit.

Role(s): Employment,_management_position,_independent_contractor_(including_contracted_research),_consulting,_speaking_and_teaching,_membership_on_advisory_committees_or_review_panels,_board_membership,_and_other_activities_(please_specify).

Glossary of Terms

commercial Interest -_The_ACCME_defines_a_“commercial_interest”_as_any_proprietary_entity_producing_health_care_goods_or_services,_used_on,_or_consumed_by,_patients,_with_the_exemption_of_non-profit_or_government_organizations_and_non-health_care_related_companies.Financial Relationships -_Financial_relationships_are_those_relationships_in_which_the_individual_benefits_by_receiving_a_salary,_royalty,_ intellectual_property_rights,_consulting_fee,_honoraria,_ownership_interest_(e.g.,_stocks,_stock_options_or_other_ownership_interest,_excluding_diversified_mutual_funds),_or_other_financial_benefit._ _Financial_benefits_are_usually_associated_with_ roles_such_as_employment,_management_position,_ independent_contractor_(including_contracted_research),_consulting,_speaking_and_teaching,_membership_on_advisory_committees_or_review_panels,_board_membership,_and_other_activities_from_which_remuneration_is_received,_or_expected.__ACCME_considers_relationships_of_the_person_involved_in_the_CME_activity_to_include_financial_relationships_of_a_spouse_or_partner.

Relevant Financial Relationships -_ACCME_focuses_on_financial_relationships_with_commercial_interests_in_the_12-month_period_preceding_the_time_that_the_individual_is_being_asked_to_assume_a_role_controlling_content_of_the_CME_activity._ACCME_has_not_set_a_minimal_dollar_amount_for_relationships_to_be_significant.__Inherent_in_any_amount_is_the_incentive_to_maintain_or_increase_the_value_of_the_relationship._The_ACCME_defines_“relevant_financial_relationships”_as_financial_relationships_in_any_amount_occurring_within_the_past_12_months_that_create_a_conflict_of_interest.conflict of Interest -_Circumstances_create_a_conflict_of_interest_when_an_individual_has_an_opportunity_to_affect_CME_content_about_products_or_services_of_a_commercial_interest_with_which_he/she_has_a_financial_relationship.

Early_RegistrationBy_March_15,_2011

Still-Time-To_RegBy_May_28,_2011

Late/On-SiteAfter_May_28,_2011

AAPS_Diplomate/_Emeritus/__Member

CME_Package $525 $725 $925Business_Package $295 $495 $695Discount_Package $725 $1125 $1525

PresenterCME_Package $325 $525 NABusiness_Package $295 $495 NADiscount_Package $525_ $925 NA

AAPS_RetiredCME_Package $325 $525 $725Business_Package $295 $495 $695Discount_Package $525 $925 $1325

Non-Member CME_Package $650 $850 $1050

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