continuing education NAMSS CE Quiz: Questions on Dealing with Disruptive Physicians Instructions: Make a photocopy of this form – DO NOT REMOVE THE PAGE from the magazine so that others also may use it to obtain CE credit . Print your name and address in the form below . This form will be mailed back to you to use as your CE credit certificate . DEADLINE TO SUBMIT YOUR QUIZ FOR CREDIT IS JUNE 2014 . Take this quiz online and receive your results immediately! Click the SYNERGY Quizzes link in the Headlines section of www.namss.org. Name: Facility: Address: City/State/ZIP: Title: Business Phone: Signature: Date: Answers Place an “X” in the box next to the correct answer . True/False and Multiple Choice Payment Information ❑ Processing Fee: $15 members OR $25 non-members ❑ Check Payment: Enclosed is a check or money order payable to NAMSS (DO NOT SEND CASH) . Check No .: Date: 1 . a . ❑ b . ❑ 2 . a . ❑ b . ❑ 3 . a . ❑ b . ❑ 4 . a . ❑ b . ❑ 5 . a . ❑ b . ❑ 6 . a . ❑ b . ❑ 7 . a . ❑ b . ❑ 8 . a . ❑ b . ❑ Cardholder’s Name (PLEASE PRINT): 9 . a . ❑ b . ❑ Facility (IF APPLICABLE): 10 . a . ❑ b . ❑ Cardholder’s Address: Amount: $ Check one: ❑ Facility Check ❑ Credit Card Payment*: Check one: ❑ MC ❑ Visa ❑ Personal Check ❑ AMEX ❑ Discover I authorize NAMSS to charge my credit card $ c . ❑ d . ❑ Credit Card No .: Exp . Date: City/State/ZIP: For NAMSS Executive Office Use Only Score: ❑ You have passed this quiz and earned one (1) Category I CE clock hour . ❑ You scored below 80% and DO NOT earn CE credit . NOTE: No record will be kept at NAMSS of this quiz . Keep this form as evidence of completion . 28 / SYNERGY MaY/JUNE 2013 Cardholder’s Phone: Authorized Signature: *Credit card submissions must be mailed in, and to maintain you (the submitter’s) security, faxes will not be accepted . I understand my billing statement will read “NAMSS.” If rebilling a credit card is necessary, a $25 processing fee will be charged . A charge of $25 will apply for all non-sufficient fund checks . Mail To: NAMSS Attention CE Department 2025 M Street, NW, #800 Washington, DC 20036http://www.namss.org/AnnualConference/NAMSS37thEducationalConferenceInformation/tabid/348/Default.aspx